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1.  Effective Sharing of Health Records, Maintaining Privacy: A Practical Schema 
A principal goal of computerisation of medical records is to join up care services for patients, so that their records can follow them wherever they go and thereby reduce delays, duplications, risks and errors, and costs. Healthcare records are increasingly being stored electronically, which has created the necessary conditions for them to be readily sharable. However simply driving the implementation of electronic medical records is not sufficient, as recent developments have demonstrated (1): there remain significant obstacles.
The three main obstacles relate to (a) record accessibility (knowing where event records are and being able to access them), (b) maintaining privacy (ensuring that only those authorised by the patient can access and extract meaning from the records) and (c) assuring the functionality of the shared information (ensuring that the records can be shared non-proprietorially across platforms without loss of meaning, and that their authenticity and trustworthiness are demonstrable). These constitute a set of issues that need new thinking, since existing systems are struggling to deliver them.
The solution to this puzzle lies in three main parts. Clearly there is only one environment suited to such widespread sharing, which is the World Wide Web, so this is the communications basis. Part one requires that a sharable synoptic record is created for each care event and stored in standard web-format and in readily accessible locations, on ‘the web’ or in ‘the cloud’. To maintain privacy these publicly-accessible records must be suitably protected either stripped of identifiers (names, addresses, dates, places etc.) and/or encrypted: either way the record must be tagged with a tag that means nothing to anyone, but serves to identify and authenticate a specific record when retrieved. For ease of retrieval patients must hold an index of care events, records and web locations (plus any associated information for each such as encryption keys, context etc.). For added security, as well as for trustworthiness, a method of verifying authenticity, integrity and authorship is required, which can be provided using a public key infrastructure (PKI) for cryptography (2). The second part of the solution is to give control over record access and sharing to the patient (or their identified representative), enabling them to authorise access by providing the index and access keys to their records. This can be done using a token (fe.g. smart card) or a secure online index which holds these details: this serves to relieve the formal record keeper of responsibility for external access control and privacy (internal access control and privacy can remain an institutional responsibility). The third part of the solution is to process the content of the stored records such that there is a ‘plain English’ copy, as well as an electronic copy which is coded and marked up using XML tags for each data element to signify ‘type’ (e.g. administrative, financial, operational, clinical etc.) and sub-types (e.g. diagnosis, medication, procedure,
investigation result etc.). This ensures that the recipient can always read the data using a basic browser, but can readily manipulate and re-arrange the data for display and storage if they have a more sophisticated installation.
doi:10.5210/ojphi.v5i2.4344
PMCID: PMC3733761  PMID: 23923101
2.  The impact of the Quality and Outcomes Framework (QOF) on the recording of smoking targets in primary care medical records: cross-sectional analyses from The Health Improvement Network (THIN) database 
BMC Public Health  2012;12:329.
Background
Smoking is a UK public health threat but GPs can be effective in helping patients to quit; consequently, the Quality and Outcomes Framework (QOF) incentivises the recording of smoking status and delivery of cessation advice in patients’ medical records. This study investigates the association between smoking-related QOF targets and such recording, and the factors which influence these clinical activities.
Methods
For 2000 to 2008, using medical records in The Health Improvement Network (THIN) database, the annual proportions of i) patients who had a record of smoking status made in the previous 27 months and ii) current smokers recorded as receiving cessation advice in the previous 15 months were calculated. Then, for all patients at selected points before and after the QOF’s implementation, data on gender, age, Townsend score, and smoking-related morbidity were extracted. Multivariate logistic regression was used to investigate individual-level characteristics associated with the recording of smoking status and cessation advice.
Results
Rapid increases in recording smoking status and advice occurred around the QOF’s introduction in April 2004. Subsequently, compliance to targets has been sustained, although rates of increase have slowed. By 2008 64.5% of patients aged 15+ had smoking status documented in the previous 27 months and 50.5% of current smokers had cessation advice recorded in the last 15 months. Adjusted odds ratios show that, both before and after the introduction of the QOF, those with chronic medical conditions, greater social deprivation and women were more likely to have a recent recording of smoking status or cessation advice. Since the QOF’s introduction, the strongest characteristic associated with recording activities was the presence of co-morbidity. An example of this was patients with COPD, who in 2008, were 15.38 (95% CI 13.70-17.27) times and 11.72 (95% CI 10.41-13.21) times more likely to have a record of smoking status and cessation advice, respectively.
Conclusions
Rates of recording smoking status and cessation advice plateaued after large increases during the QOF’s introduction; however, recording remains most strongly associated with the presence of chronic disease as specified by the QOF, and suggests that incentivised targets have a direct effect on clinical behaviour.
doi:10.1186/1471-2458-12-329
PMCID: PMC4104830  PMID: 22559290
Smoking; Quality and Outcomes Framework (QOF); Targets
3.  The Use of Automated Bioacoustic Recorders to Replace Human Wildlife Surveys: An Example Using Nightjars 
PLoS ONE  2014;9(7):e102770.
To be able to monitor and protect endangered species, we need accurate information on their numbers and where they live. Survey methods using automated bioacoustic recorders offer significant promise, especially for species whose behaviour or ecology reduces their detectability during traditional surveys, such as the European nightjar. In this study we examined the utility of automated bioacoustic recorders and the associated classification software as a way to survey for wildlife, using the nightjar as an example. We compared traditional human surveys with results obtained from bioacoustic recorders. When we compared these two methods using the recordings made at the same time as the human surveys, we found that recorders were better at detecting nightjars. However, in practice fieldworkers are likely to deploy recorders for extended periods to make best use of them. Our comparison of this practical approach with human surveys revealed that recorders were significantly better at detecting nightjars than human surveyors: recorders detected nightjars during 19 of 22 survey periods, while surveyors detected nightjars on only six of these occasions. In addition, there was no correlation between the amount of vocalisation captured by the acoustic recorders and the abundance of nightjars as recorded by human surveyors. The data obtained from the recorders revealed that nightjars were most active just before dawn and just after dusk, and least active during the middle of the night. As a result, we found that recording at both dusk and dawn or only at dawn would give reasonably high levels of detection while significantly reducing recording time, preserving battery life. Our analyses suggest that automated bioacoustic recorders could increase the detection of other species, particularly those that are known to be difficult to detect using traditional survey methods. The accuracy of detection is especially important when the data are used to inform conservation.
doi:10.1371/journal.pone.0102770
PMCID: PMC4100896  PMID: 25029035
4.  Smoking cessation advice recorded during pregnancy in United Kingdom primary care 
BMC Family Practice  2014;15:21.
Background
United Kingdom (UK) national guidelines recommend that all pregnant women who smoke should be advised to quit at every available opportunity, and brief cessation advice is an efficient and cost-effective means to increase quit rates. The Quality and Outcomes Framework (QOF) implemented in 2004 requires general practitioners to document their delivery of smoking cessation advice in patient records. However, no specific targets have been set in QOF for the recording of this advice in pregnant women. We used a large electronic primary care database from the UK to quantify the pregnancies in which women who smoked were recorded to have been given smoking cessation advice, and the associated maternal characteristics.
Methods
Using The Health Improvement Network database we calculated annual proportions of pregnant smokers between 2000 and 2009 with cessation advice documented in their medical records during pregnancy. Logistic regression was used to assess variation in the recording of cessation advice with maternal characteristics.
Results
Among 45,296 pregnancies in women who smoked, recorded cessation advice increased from 7% in 2000 to 37% in 2004 when the QOF was introduced and reduced slightly to 30% in 2009. Pregnant smokers from the youngest age group (15–19) were 21% more likely to have a record of cessation advice compared to pregnant smokers aged 25–29 (OR 1.21, 95% CI 1.10-1.35) and pregnant smokers from the most deprived group were 38% more likely to have a record for cessation advice compared to pregnant smokers from the least deprived group (OR 1.38, 95% CI 1.14-1.68). Pregnant smokers with asthma were twice as likely to have documentation of cessation advice in their primary care records compared to pregnant smokers without asthma (OR 1.97, 95% CI 1.80-2.16). Presence of comorbidities such as diabetes, hypertension and mental illness also increased the likelihood of having smoking cessation advice recorded. No marked variations were observed in the recording of cessation advice with body mass index.
Conclusion
Recorded delivery of smoking cessation advice for pregnant smokers in primary care has increased with some fluctuation over the years, especially after the implementation of the QOF, and varies with maternal characteristics.
doi:10.1186/1471-2296-15-21
PMCID: PMC3930304  PMID: 24484239
Pregnancy; Smoking; Primary care; Smoking cessation advice
5.  In vivo magnetic and electric recordings from nerve bundles and single motor units in mammalian skeletal muscle. Correlations with muscle force 
The Journal of General Physiology  1991;98(5):1043-1061.
Recent advances in the technology of recording magnetic fields associated with electric current flow in biological tissues have provided a means of examining action currents that is more direct and possibly more accurate than conventional electrical recording. Magnetic recordings are relatively insensitive to muscle movement, and, because the recording probes are not directly connected to the tissue, distortions of the data due to changes in the electrochemical interface between the probes and the tissue are eliminated. In vivo magnetic recordings of action currents of rat common peroneal nerve and extensor digitorum longus (EDL) muscle were obtained by a new magnetic probe and amplifier system that operates within the physiological temperature range. The magnetically recorded waveforms were compared with those obtained simultaneously by conventional, extracellular recording techniques. We used the amplitude of EDL twitch force (an index of stimulus strength) generated in response to graded stimulation of the common peroneal nerve to enable us to compare the amplitudes of magnetically recorded nerve and muscle compound action currents (NCACs and MCACs, respectively) with the amplitudes of electrically recorded nerve compound action potentials (NCAPs). High, positive correlations to stimulus strength were found for NCACs (r = 0.998), MCACs (r = 0.974), and NCAPs (r = 0.998). We also computed the correlations of EDL single motor unit twitch force with magnetically recorded single motor unit compound action currents (SMUCACs) and electrically recorded single motor unit compound action potentials (SMUCAPs) obtained with both a ring electrode and a straight wire serving as a point electrode. Only the SMUCACs had a relatively strong positive correlation (r = 0.768) with EDL twitch force. Correlations for ring and wire electrode- recorded SMUCAPs were 0.565 and -0.366, respectively. This study adds a relatively direct examination of action currents to the characterization of the normal biophysical properties of peripheral nerve, muscle, and muscle single motor units.
PMCID: PMC2229093  PMID: 1765761
6.  Completeness of Maternal Smoking Status Recording during Pregnancy in United Kingdom Primary Care Data 
PLoS ONE  2013;8(9):e72218.
Background
Given the health impacts of smoking during pregnancy and the opportunity for primary healthcare teams to encourage pregnant smokers to quit, our primary aim was to assess the completeness of gestational smoking status recording in primary care data and investigate whether completeness varied with women's characteristics. As a secondary aim we assessed whether completeness of recording varied before and after the introduction of the Quality and Outcomes Framework (QOF).
Methods
In The Health Improvement Network (THIN) database we calculated the proportion of pregnancies ending in live births or stillbirths where there was a recording of maternal smoking status for each year from 2000 to 2009. Logistic regression was used to assess variation in the completeness of maternal smoking recording by maternal characteristics, before and after the introduction of QOF.
Results
Women had a record of smoking status during the gestational period in 28% of the 277,552 pregnancies identified. In 2000, smoking status was recorded in 9% of pregnancies, rising to 43% in 2009. Pregnant women from the most deprived group were 17% more likely to have their smoking status recorded than pregnant women from the least deprived group before QOF implementation (OR 1.17, 95% CI 1.10–1.25) and 42% more likely afterwards (OR 1.42, 95% CI 1.37–1.47). A diagnosis of asthma was related to recording of smoking status during pregnancy in both the pre-QOF (OR 1.63, 95% CI 1.53–1.74) and post-QOF periods (OR 2.08, 95% CI 2.02–2.15). There was no association between having a diagnosis of diabetes and recording of smoking status during pregnancy pre-QOF however, post-QOF diagnosis of diabetes was associated with a 12% increase in recording of smoking status (OR 1.12, 95% CI 1.05–1.19).
Conclusion
Recording of smoking status during pregnancy in primary care data is incomplete though has improved over time, especially after the implementation of the QOF, and varies by maternal characteristics and QOF-incentivised morbidities.
doi:10.1371/journal.pone.0072218
PMCID: PMC3777944  PMID: 24069143
7.  The role of home-based records in the establishment of a continuum of care for mothers, newborns, and children in Indonesia 
Global Health Action  2013;6:10.3402/gha.v6i0.20429.
Background
The provision of appropriate care along the continuum of maternal, newborn, and child health (MNCH) service delivery is a challenge in developing countries. To improve this, in the 1990s, Indonesia introduced the maternal and child health (MCH) handbook, as an integrated form of parallel home-based records.
Objective
This study aimed to identify the roles of home-based records both before and after childbirth, especially in provinces where the MCH handbook (MCHHB) was extensively promoted, by examining their association with MNCH service uptake.
Design
This was a cross-sectional study using nationally representative data sets, the Indonesia Demographic and Health Surveys (IDHSs) from 1997, 2002–2003, and 2007. The IDHS identifies respondents’ ownership of home-based records before and after childbirth. Multivariate logistic regression was used to examine associations between record ownership and service utilisation in national data and data from two provinces, West Sumatra and North Sulawesi, where ownership of pre- and post-natal records served as a proxy for MCHHB ownership.
Results
Pre- and post-natal record ownership increased from 1997 to 2007. Provincial data from 2007 showed that handbook ownership was associated with having delivery assisted by trained personnel [adjusted odds ratio (aOR): 2.12, 95% confidence interval (CI): 1.05–4.25], receiving maternal care (aOR: 3.92, 95% CI: 2.35–6.52), completing 12 doses of child immunisation for seven diseases (aOR: 4.86, 95% CI: 2.37–9.95), and having immunisation before and after childbirth (aOR: 5.40, 95% CI: 2.28–12.76), whereas national data showed that service utilisation was associated with ownership of both records compared with owning a single record or none.
Conclusion
Our results suggest that pre- and post-natal home-based record use may be effective for ensuring service utilisation. In addition, since the handbook is an efficient home-based record for use throughout children's life courses, it could be an effective tool for promoting the continuum of MNCH care in Indonesia.
doi:10.3402/gha.v6i0.20429
PMCID: PMC3647040  PMID: 23651873
continuum of care; maternal; newborn and child health; personal health record; Maternal and Child Health handbook; Indonesia
8.  Unified method to integrate and blend several, potentially related, sources of information for genetic evaluation 
Background
A condition to predict unbiased estimated breeding values by best linear unbiased prediction is to use simultaneously all available data. However, this condition is not often fully met. For example, in dairy cattle, internal (i.e. local) populations lead to evaluations based only on internal records while widely used foreign sires have been selected using internally unavailable external records. In such cases, internal genetic evaluations may be less accurate and biased. Because external records are unavailable, methods were developed to combine external information that summarizes these records, i.e. external estimated breeding values and associated reliabilities, with internal records to improve accuracy of internal genetic evaluations. Two issues of these methods concern double-counting of contributions due to relationships and due to records. These issues could be worse if external information came from several evaluations, at least partially based on the same records, and combined into a single internal evaluation. Based on a Bayesian approach, the aim of this research was to develop a unified method to integrate and blend simultaneously several sources of information into an internal genetic evaluation by avoiding double-counting of contributions due to relationships and due to records.
Results
This research resulted in equations that integrate and blend simultaneously several sources of information and avoid double-counting of contributions due to relationships and due to records. The performance of the developed equations was evaluated using simulated and real datasets. The results showed that the developed equations integrated and blended several sources of information well into a genetic evaluation. The developed equations also avoided double-counting of contributions due to relationships and due to records. Furthermore, because all available external sources of information were correctly propagated, relatives of external animals benefited from the integrated information and, therefore, more reliable estimated breeding values were obtained.
Conclusions
The proposed unified method integrated and blended several sources of information well into a genetic evaluation by avoiding double-counting of contributions due to relationships and due to records. The unified method can also be extended to other types of situations such as single-step genomic or multi-trait evaluations, combining information across different traits.
Electronic supplementary material
The online version of this article (doi:10.1186/s12711-014-0059-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12711-014-0059-3
PMCID: PMC4179859
9.  Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation 
Objective To clinically evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia.
Design Prospective randomised open label clinical trial.
Setting Five designated operating theatres in a major tertiary referral hospital.
Participants Eighty nine consenting anaesthetists managing 1075 cases in which there were 10 764 drug administrations.
Intervention Use of the new system (which includes customised drug trays and purpose designed drug trolley drawers to promote a well organised anaesthetic workspace and aseptic technique; pre-filled syringes for commonly used anaesthetic drugs; large legible colour coded drug labels; a barcode reader linked to a computer, speakers, and touch screen to provide automatic auditory and visual verification of selected drugs immediately before each administration; automatic compilation of an anaesthetic record; an on-screen and audible warning if an antibiotic has not been administered within 15 minutes of the start of anaesthesia; and certain procedural rules—notably, scanning the label before each drug administration) versus conventional practice in drug administration with a manually compiled anaesthetic record.
Main outcome measures Primary: composite of errors in the recording and administration of intravenous drugs detected by direct observation and by detailed reconciliation of the contents of used drug vials against recorded administrations; and lapses in responding to an intermittent visual stimulus (vigilance latency task). Secondary: outcomes in patients; analyses of anaesthetists’ tasks and assessments of workload; evaluation of the legibility of anaesthetic records; evaluation of compliance with the procedural rules of the new system; and questionnaire based ratings of the respective systems by participants.
Results The overall mean rate of drug errors per 100 administrations was 9.1 (95% confidence interval 6.9 to 11.4) with the new system (one in 11 administrations) and 11.6 (9.3 to 13.9) with conventional methods (one in nine administrations) (P=0.045 for difference). Most were recording errors, and, though fewer drug administration errors occurred with the new system, the comparison with conventional methods did not reach significance. Rates of errors in drug administration were lower when anaesthetists consistently applied two key principles of the new system (scanning the drug barcode before administering each drug and keeping the voice prompt active) than when they did not: mean 6.0 (3.1 to 8.8) errors per 100 administrations v 9.7 (8.4 to 11.1) respectively (P=0.004). Lapses in the vigilance latency task occurred in 12% (58/471) of cases with the new system and 9% (40/473) with conventional methods (P=0.052). The records generated by the new system were more legible, and anaesthetists preferred the new system, particularly in relation to long, complex, and emergency cases. There were no differences between new and conventional systems in respect of outcomes in patients or anaesthetists’ workload.
Conclusions The new system was associated with a reduction in errors in the recording and administration of drugs in anaesthesia, attributable mainly to a reduction in recording errors. Automatic compilation of the anaesthetic record increased legibility but also increased lapses in a vigilance latency task and decreased time spent watching monitors.
Trial registration Australian New Zealand Clinical Trials Registry No 12608000068369.
doi:10.1136/bmj.d5543
PMCID: PMC3178276  PMID: 21940742
10.  A Validity Review of the NBR 
Objective
Health-related registries arose due from clinician desire to improve patient quality of care for a specific disorder. As such, disease registries differ from administrative registries in concept, organization, purpose, data recording, and results. Due to their voluntary nature, health-related disease registries are not regularly audited, have a narrow focus, and are designed for clinicians, not administrators. As part of a Department of Defense initiative we conducted an intensive qualitative review of the American Burn Association’s National Burn Repository (NBR). Our objectives are to inform future users of the NBR of issues that could affect statistical analyses and inferences and assist efforts to improve data collection.
Methods
We obtained a deidentified copy of the 2009 release of the NBR containing 286,293 records. We reviewed this data set for 1) records lacking vital patient information (age, burn size, survival, gender), 2) inconsistencies between data in different fields of the database, and 3) duplicate values.
Results
Restricting our review to records with an admission year of 2000 or later, vital patient information was missing or invalid for about 60,000 records. Data inconsistencies were found in hospital admission status (initial admission or readmission) for about 12,000 records, survival for about 950 records, and burn injury for about 5,500 records. Depending on the criteria used to identify duplicate records, we found at least 4,000 duplicate records but as many as 14,000 in the database. Finally, significant data quality issues were found for facilities not using the TRACS software.
Conclusions
All health-related disease registries, unlike administrative databases, are voluntary. Anonymity of data is vital, and data auditing and reporting are challenging. The data contained in the NBR is disease-specific, and, as such, has the potential to provide valuable epidemiologic, treatment, and outcome data as reported by clinicians, not registrars. The NBR provides substantive data on burn injury; however, data review needs to precede data analysis. Revisions to NBR data collection have improved the quality of data submitted, yet data quality issues remain in the current database. Investigators are cautioned to thoroughly assess all fields prior to conducting analyses using the NBR.
doi:10.1097/BCR.0b013e3182642b46
PMCID: PMC3567245  PMID: 23128133
National Burn Repository; health registry; burns
11.  AnthWest, occurrence records for wool carder bees of the genus Anthidium (Hymenoptera, Megachilidae, Anthidiini) in the Western Hemisphere 
ZooKeys  2014;31-49.
This paper describes AnthWest, a large dataset that represents one of the outcomes of a comprehensive, broadly comparative study on the diversity, biology, biogeography, and evolution of Anthidium Fabricius in the Western Hemisphere. In this dataset a total of 22,648 adult occurrence records comprising 9657 unique events are documented for 92 species of Anthidium, including the invasive range of two introduced species from Eurasia, A. oblongatum (Illiger) and A. manicatum (Linnaeus). The geospatial coverage of the dataset extends from northern Canada and Alaska to southern Argentina, and from below sea level in Death Valley, California, USA, to 4700 m a.s.l. in Tucumán, Argentina. The majority of records in the dataset correspond to information recorded from individual specimens examined by the authors during this project and deposited in 60 biodiversity collections located in Africa, Europe, North and South America. A fraction (4.8%) of the occurrence records were taken from the literature, largely California records from a taxonomic treatment with some additional records for the two introduced species. The temporal scale of the dataset represents collection events recorded between 1886 and 2012. The dataset was developed employing SQL server 2008 r2. For each specimen, the following information is generally provided: scientific name including identification qualifier when species status is uncertain (e.g. “Questionable Determination” for 0.4% of the specimens), sex, temporal and geospatial details, coordinates, data collector, host plants, associated organisms, name of identifier, historic identification, historic identifier, taxonomic value (i.e., type specimen, voucher, etc.), and repository. For a small portion of the database records, bees associated with threatened or endangered plants (~ 0.08% of total records) as well as specimens collected as part of unpublished biological inventories (~17%), georeferencing is presented only to nearest degree and the information on floral host, locality, elevation, month, and day has been withheld. This database can potentially be used in species distribution and niche modeling studies, as well as in assessments of pollinator status and pollination services. For native pollinators, this large dataset of occurrence records is the first to be simultaneously developed during a species-level systematic study.
doi:10.3897/zookeys.408.5633
PMCID: PMC4042824  PMID: 24899835
Anthophila; Apoidea; bees; invasive species; North America; South America; pollinators; biodiversity; floral hosts
12.  ELECTRICAL SIGNS OF IMPULSE CONDUCTION IN SPINAL MOTONEURONS 
The Journal of General Physiology  1951;35(2):255-288.
An analysis has been made of the electrical responses recorded on the surface and within the substance of the first sacral spinal segment when the contained motoneurons are excited by single and repeated antidromic ventral root volleys. A succession of negative deflections, designated in order of increasing latency m, i, b, d, has been found. Each of those deflections possesses some physiological property or properties to distinguish it from the remainder. Indicated by that fact is the conclusion that the successive deflections represent impulse conduction through successive parts of the motoneurons that differ in behavior, each from the others. Since the spinal cord constitutes a volume conductor the negative deflections are anteceded by a positive deflection at all points except that at which the axonal impulses first enter from the ventral root into the spinal cord. Frequently two or more negative deflections are recorded together in overlapping sequence, but for each deflection a region can be found in which the onset of that deflection marks the transition from prodromal positivity to negativity. Deflection m is characteristic of axonal spikes. Latent period is in keeping with known axonal conduction velocity. Refractory period is brief. The response represented by m is highly resistant to asphyxia. Maximal along the line of ventral root attachment and attenuating sharply therefrom, deflection m can be attributed only to axonal impulse conduction. Deflection i is encountered only within the cord, and is always associated with a deflection b. The i,b complex is recordable at loci immediately dorsal to regions from which m is recorded, and immediately ventral to points from which b is recorded in isolation from i. Except for its great sensitivity to asphyxia, deflection i has properties in common with those of m, but very different from those of b or d. To judge by properties i represents continuing axonal impulse conduction into a region, however, that is readily depolarized by asphyxia. Deflection b possesses a unique configuration in that the ascending limb is sloped progressively to the right indicating a sharp decrease in velocity of the antidromic impulses penetrating the b segment. A second antidromic volley will not conduct from i segment to b segment of the motoneurons unless separated from the first by nearly 1 msec. longer than is necessary for restimulation of axons. This value accords with somatic refractoriness determined by other means. Together with spatial considerations, the fact suggests that b represents antidromic invasion of cell bodies. Deflection d is ubiquitous, but in recordings from regions dorsal and lateral to the ventral horn, wherein an electrode is close to dendrites, but remote from other segments of motoneurons, d is the initial negative deflection. In latency d is variable to a degree that demands that it represent slow conduction through rather elongated structures. When associated with deflection b, deflection d may arise from the peak of b with the only notable discontinuity provided by the characteristically sloped rising phase of b. Deflection d records the occupation by antidromic impulses of the dendrites. Once dendrites have conducted a volley they will not again do so fully for some 120 msec. Embracing the several deflections, recorded impulse negativity in the motoneurons may endure for nearly 5 msec. When the axonal deflection m is recorded with minimal interference from somatic currents, it is followed by a reversal of sign to positivity that endures as long as impulse negativity can be traced elsewhere, demonstrating the existence of current flow from axons to somata as the latter are occupied by impulses. Note is taken of the fact that impulse conduction through motoneurons is followed by an interval, measurable to some 120 msec., during which after-currents flow. These currents denote the existence in parts of the intramedullary motoneurons of after-potentials the courses of which must differ in different parts of the neurons, otherwise nothing would be recorded. The location of sources and sinks is such as to indicate that a major fraction of the current flows between axons and somata. For approximately 45 msec. the direction of flow is from dendrites to axons. Thereafter, and for the remaining measurable duration, flow is from axons to dendrites.
PMCID: PMC2147290  PMID: 14898018
13.  Predictors of validity and reliability of a physical activity record in adolescents 
BMC Public Health  2013;13:1109.
Background
Poor to moderate validity of self-reported physical activity instruments is commonly observed in young people in low- and middle-income countries. However, the reasons for such low validity have not been examined in detail. We tested the validity of a self-administered daily physical activity record in adolescents and assessed if personal characteristics or the convenience level of reporting physical activity modified the validity estimates.
Methods
The study comprised a total of 302 adolescents from an urban and rural area in Ecuador. Validity was evaluated by comparing the record with accelerometer recordings for seven consecutive days. Test-retest reliability was examined by comparing registrations from two records administered three weeks apart. Time spent on sedentary (SED), low (LPA), moderate (MPA) and vigorous (VPA) intensity physical activity was estimated. Bland Altman plots were used to evaluate measurement agreement. We assessed if age, sex, urban or rural setting, anthropometry and convenience of completing the record explained differences in validity estimates using a linear mixed model.
Results
Although the record provided higher estimates for SED and VPA and lower estimates for LPA and MPA compared to the accelerometer, it showed an overall fair measurement agreement for validity. There was modest reliability for assessing physical activity in each intensity level. Validity was associated with adolescents’ personal characteristics: sex (SED: P = 0.007; LPA: P = 0.001; VPA: P = 0.009) and setting (LPA: P = 0.000; MPA: P = 0.047). Reliability was associated with the convenience of completing the physical activity record for LPA (low convenience: P = 0.014; high convenience: P = 0.045).
Conclusions
The physical activity record provided acceptable estimates for reliability and validity on a group level. Sex and setting were associated with validity estimates, whereas convenience to fill out the record was associated with better reliability estimates for LPA. This tendency of improved reliability estimates for adolescents reporting higher convenience merits further consideration.
doi:10.1186/1471-2458-13-1109
PMCID: PMC3890530  PMID: 24289296
Accelerometers; Convenience; Diary; Ecuador; Low- and middle-income countries; Validity
14.  A cluster randomised controlled trial of patient-held medical records for people with schizophrenia receiving shared care. 
BACKGROUND: Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear. AIM: To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999. METHOD: A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services. RESULTS: A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record. CONCLUSIONS: The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.
PMCID: PMC1314544  PMID: 14694695
15.  Impact of a Computer-based Patient Record System on Data Collection, Knowledge Organization, and Reasoning 
Objective: To assess the effects of a computer-based patient record system on human cognition. Computer-based patient record systems can be considered "cognitive artifacts," which shape the way in which health care workers obtain, organize, and reason with knowledge.
Design: Study 1 compared physicians' organization of clinical information in paper-based and computer-based patient records in a diabetes clinic. Study 2 extended the first study to include analysis of doctor–patient–computer interactions, which were recorded on video in their entirety. In Study 3, physicians' interactions with computer-based records were followed through interviews and automatic logging of cases entered in the computer-based patient record.
Results: Results indicate that exposure to the computer-based patient record was associated with changes in physicians' information gathering and reasoning strategies. Differences were found in the content and organization of information, with paper records having a narrative structure, while the computer-based records were organized into discrete items of information. The differences in knowledge organization had an effect on data gathering strategies, where the nature of doctor-patient dialogue was influenced by the structure of the computer-based patient record system.
Conclusion: Technology has a profound influence in shaping cognitive behavior, and the potential effects of cognition on technology design needs to be explored.
PMCID: PMC129666  PMID: 11062231
16.  The quality of electronic patient records in Finnish primary healthcare needs to be improved 
Objective
To analyse the technical quality of electronic patient records in relation to legislation and to evaluate their quality associated with the quality of consultations as rated by patients and GPs.
Design
Cross-sectional study of electronic patient records.
Setting
Four primary healthcare (PHC) centres in Finland using three different electronic patient record systems.
Subjects
Patient records of 175 PHC consultations by 50 GPs, rated as the best (n=86) and the worst (n=89) of a total of 2191 consultations.
Main outcome measures
Documentation of records compared with legislation, the general informative value of records, and its relation to the experienced quality of consultations and to the electronic system employed.
Results
Reason for encounter was mentioned in 79% of cases and patient history in 32%. An acute problem was described moderately well or well in 84%, examination findings in 62%, medical problem or diagnosis in 90%, and treatment in 95% of cases. Medication was documented adequately in 38% of the cases where medication was documented. Concerning general informative value, 18% were assessed as poor, 62% as moderate, and 20% as good. No correspondence was found between experienced quality of consultation and general informative value in the patient records. The quality of patient records was found to change according to the electronic system employed.
Conclusions
Finnish patient records are inadequate documents of consultations and below the standard of that country's legislation. Developing better models of recording would guarantee a higher quality of work.
doi:10.1080/02813430701868806
PMCID: PMC3406647  PMID: 18570011
Family medicine; family practice; patient record; quality of consultation
17.  A comparative evaluation of dimensional stability of three types of interocclusal recording materials-an in-vitro multi-centre study 
Head & Face Medicine  2012;8:27.
Background
The introduction of different interocclusal recording materials has put clinicians in dilemma that which material should be used in routine clinical practice for precise recording and transferring of accurate existing occlusal records for articulation of patient’s diagnostic or working casts in the fabrication of good satisfactory prosthesis. In the era of developing world of dentistry the different materials are introduced for interocclusal record with different brand names because of this; the utility of the material is confusing for successful delivery of prosthesis with lack of in vitro or in vivo studies which will predict the property of the material with utility recommendations.
Purpose of the study
The aim of this multicenter research is to evaluate the time dependent linear dimensional stability of three types of interocclusal recording materials; which gives very clear idea to clinicians in regard to its usage in routine practice and recommendations for usage of the different materials. Also to find out ideal time for articulation of three types of interocclusal recording materials with accuracy.
Materials and method
Commercially available and ADA approved Polyether bite registration paste (Ramitec), Poly vinyl siloxane bite registration paste (Jetbite) and Zinc oxide eugenol (ZOE) bite registration paste (Super bite) were used in the study.
A stainless steel die was made according to modified American dental Associations (ADA) specification no. 19. Each one of the tested materials were manipulated according to manufacturers’ instructions. The materials separated from die, 3-mins after their respective setting time, resulted in disks of standard diameter. Two parallel lines and three perpendicular lines reproduced on the surface. The distance between two parallel lines was measured at different time intervals i.e. 1 hour, 24, 48 and 72 hours by using travelling microscope (magnus) and compared with standard die measurements made according to ADA specification no.19 to find out the dimensional stability of these interocclusal recording materials. Total 120 samples were made for observation and results were subjected to statistical analysis. Statistical analysis was performed using analysis of variance (ANOVA) and then Tukey’s Honestly Significant Difference (HSD) test for comparison among groups at the 0.05 level of significance. After statistical analysis of the data, results were obtained and analyzed for interpretation.
Results
The results shows significant difference between the dimensional stability of all three material at different intervals with p-value <0.05. Comparatively the polyether bite registration material showed less distortion with good dimensional stability compared to Poly vinyl siloxane bite (Jetbite), Zinc oxide eugenol(ZOE) bite (Super bite) at 1 hour, 24, 48, and 72 hours.
Conclusion
The dimensional stability decreased with increase in time and is influenced by both material factor and time factor. Polyether was found to be more dimensionally stable interocclusal recording material, which was followed by Silicone and Zinc oxide eugenol (ZOE). The dimensional stability of Polyether was good. Zinc oxide eugenol is dimensionally more unstable when compared with polyether and polyvinyl siloxane. We recommend that the polyether interocclusal records must be articulated within 48 hours and Polyvinylsiloxane interocclusal records must be articulated within 24 hours and the ZOE should be articulated within 1 hour to get a correct restoration to have very minimum distortion and maximum satisfaction without failure of prosthesis.
doi:10.1186/1746-160X-8-27
PMCID: PMC3489718  PMID: 23039395
Polyether bite; Poly vinyl siloxane bite; Zinc oxide eugenol (ZOE) bite; Dimensional stability; Interocclusal records
18.  Doctors' use of electronic medical records systems in hospitals: cross sectional survey 
BMJ : British Medical Journal  2001;323(7325):1344-1348.
Objectives
To compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.
Design
Cross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.
Setting
32 hospital units in 19 Norwegian hospitals with electronic medical records systems.
Participants
227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.
Main outcome measures
Proportion of respondents who used the electronic system, calculated for each of 23 tasks; difference in proportions of users of different systems when functionality of systems was similar.
Results
Most tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.
Conclusions
Doctors used electronic medical records systems for far fewer tasks than the systems supported.
What is already known on this topicElectronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasksWhat this study addsDoctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems
PMCID: PMC60674  PMID: 11739222
19.  A survey of validity and utility of electronic patient records in a general practice 
BMJ : British Medical Journal  2001;322(7299):1401-1405.
Objective
To develop methods of measuring the validity and utility of electronic patient records in general practice.
Design
A survey of the main functional areas of a practice and use of independent criteria to measure the validity of the practice database.
Setting
A fully computerised general practice in Skipton, north Yorkshire.
Subjects
The records of all registered practice patients.
Main outcome measures
Validity of the main functional areas of the practice clinical system. Measures of the completeness, accuracy, validity, and utility of the morbidity data for 15 clinical diagnoses using recognised diagnostic standards to confirm diagnoses and identify further cases. Development of a method and statistical toolkit to validate clinical databases in general practice.
Results
The practice electronic patient records were valid, complete, and accurate for prescribed items (99.7%), consultations (98.1%), laboratory tests (100%), hospital episodes (100%), and childhood immunisations (97%). The morbidity data for 15 clinical diagnoses were complete (mean sensitivity=87%) and accurate (mean positive predictive value=96%). The presence of the Read codes for the 15 diagnoses was strongly indicative of the true presence of those conditions (mean likelihood ratio=3917). New interpretations of descriptive statistics are described that can be used to estimate both the number of true cases that are unrecorded and quantify the benefits of validating a clinical database for coded entries.
Conclusion
This study has developed a method and toolkit for measuring the validity and utility of general practice electronic patient records.
What is already known on this topicDelivering the performance management agenda in the NHS will depend on the availability of high quality information in general practiceRecord entries in GP systems generally consist of a mixture of text and Read coded entriesSensitivity and positive predictive value have been used to measure the completeness and accuracy of data recording in electronic patient record systemsWhat this study addsThis study has developed a standard method and toolkit for measuring the validity and utility of electronic patient record systemsThe principal innovation in this study is to consider the Read codes in the records as tests for the true presence of the associated diagnosesThis study has developed a new approach to the validation of electronic patient record systems.
PMCID: PMC32256  PMID: 11397747
20.  A total audit of preventive procedures in 45 practices caring for 430,000 patients. 
BMJ : British Medical Journal  1990;300(6738):1501-1503.
OBJECTIVE--To develop and report the results of a system of audit of computer records in general practice. DESIGN--A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING--Forty five general practices, widely distributed in England and Wales. SUBJECTS--All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES--Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS--Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor's desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors' list sizes were associated with better performance. CONCLUSIONS--Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.
PMCID: PMC1663201  PMID: 2372603
21.  Accuracy of diagnosis of psychosis on general practice computer system. 
BMJ : British Medical Journal  1993;307(6895):32-34.
OBJECTIVES--To determine the accuracy of diagnoses of schizophrenia and non-affective psychosis entered by general practitioners on a computer system. To compare recording of clinical events on computer with written records. DESIGN--Examination of case notes of all patients with a computer diagnosis of psychosis. Search of 8000 randomly selected patient records to identify patients with psychosis not recorded on computer and comparison of 141 computer and written entries for prescribing and consultation in each practice. SETTING--13 London practices on the VAMP research bank. MAIN OUTCOME MEASURES--Accuracy of record of psychosis compared with ICD 9, American Psychiatric Association diagnostic manual, and syndrome checklist criteria. RESULTS--Computer search revealed 102 patients with schizophrenia, 78 with other psychoses, and 71 with non-affective psychosis who had adequate case notes. The sensitivity and positive predictive value of the computer diagnosis of schizophrenia were 88% (95% confidence interval 62% to 98%) and 71% (48% to 88%). For all non-organic psychoses sensitivity was 91% (74% to 97%) and positive predictive value was 91% (74% to 98%). On average 95% of all known prescriptions and 74% of all consultations were recorded on computer compared with 42% and 75% in written records. CONCLUSIONS--Recording of psychotic illness on the VAMP computer is accurate and complete. Prescribing was more fully recorded on the computer than on the written records. Computer databases of well motivated general practitioners could be used for research.
PMCID: PMC1678461  PMID: 8343670
22.  Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project. 
BMJ : British Medical Journal  1996;312(7031):614-617.
OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject's home. Recording of preventive information was ascertained from general practitioners' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.
PMCID: PMC2350386  PMID: 8595338
23.  Changes in deceleration capacity of heart rate and heart rate variability induced by ambient air pollution in individuals with coronary artery disease 
Background and Objective
Exposure to ambient particles has been shown to be responsible for cardiovascular effects, especially in elderly with cardiovascular disease. The study assessed the association between deceleration capacity (DC) as well as heart rate variability (HRV) and ambient particulate matter (PM) in patients with coronary artery disease (CAD).
Methods
A prospective study with up to 12 repeated measurements was conducted in Erfurt, Germany, between October 2000 and April 2001 in 56 patients with physician-diagnosed ischemic heart disease, stable angina pectoris or prior myocardial infarction at an age of at least 50 years. Twenty-minute ECG recordings were obtained every two weeks and 24-hour ECG recordings every four weeks. Exposure to PM (size range from 10 nm to 2.5 μm), and elemental (EC) and organic (OC) carbon was measured. Additive mixed models were used to analyze the association between PM and ECG recordings.
Results
The short-term recordings showed decrements in the high-frequency component of HRV as well as in RMSSD (root-mean-square of successive differences of NN intervals) in association with increments in EC and OC 0-23 hours prior to the recordings. The long-term recordings revealed decreased RMSSD and pNN50 (% of adjacent NN intervals that differed more than 50 ms) in association with EC and OC 24-47 hours prior to the recordings. In addition, highly significant effects were found for DC which decreased in association with PM2.5, EC and OC concurrent with the ECG recordings as well as with a lag of up to 47 hours.
Conclusions
The analysis showed significant effects of ambient particulate air pollution on DC and HRV parameters reflecting parasympathetic modulation of the heart in patients with CAD. An air pollution-related decrease in parasympathetic tone as well as impaired heart rate deceleration capacity may contribute to an increased risk for cardiac morbidity and sudden cardiac death in vulnerable populations.
doi:10.1186/1743-8977-7-29
PMCID: PMC2958976  PMID: 20929559
24.  Ethnicity coding in a regional cancer registry and in Hospital Episode Statistics 
BMC Public Health  2006;6:281.
Background
The collection of ethnicity information as part of cancer datasets is important for planning services and ensuring equal access, and for epidemiological studies. However, ethnicity has generally not been well recorded in cancer registries in the UK. The aim of this study was to determine the completeness of ethnicity coding in the Thames Cancer Registry (TCR) database and within the Hospital Episode Statistics (HES) data as held by the London Health Observatory, and to investigate factors associated with ethnicity being recorded.
Methods
Records for 111821 hospital admissions of London residents with a malignant cancer as a primary diagnosis between April 2002 and March 2003 and records for 25581 London residents diagnosed with cancer in 2002 were examined. Data on sex, age, cancer network of residence, deprivation, proportion of non-whites in the local authority population, and site of cancer were available. The proportion of patients in each group with a valid ethnicity code was calculated. In the TCR data proportions were also calculated adjusted for all other variables.
Results
Ethnicity was recorded for 90661 (81.1%) of the hospital admissions in the HES data and 5796 (22.7%) patients on the TCR database. Patients resident in areas with a higher proportion of non-white residents and the most deprived populations were more likely to have an ethnic code on the TCR database, though this pattern was not seen in the HES data. Adjustment did not materially affect the association between deprivation and ethnicity being recorded in the TCR data.
Conclusion
There was a large difference in completeness of ethnicity between the data sources. In order to improve the level of recording in TCR data there needs to be better recording of ethnicity in sources TCR data collection staff have access to, or use of information from other sources e.g. electronic data feeds from hospitals or pathology laboratories, or HES data itself supplied directly to TCR. Efforts to collect ethnicity data should be encouraged in all healthcare settings. Future research should explore where the difficulties collecting ethnicity information lie, whether with patients, healthcare professionals or the recording procedure, and how such problems can be overcome.
doi:10.1186/1471-2458-6-281
PMCID: PMC1657017  PMID: 17096838
25.  Assessment of the Association of Chlamydia trachomatis Infection and Adverse Perinatal Outcomes with the Use of Population-Based Chlamydia Case Report Registries and Birth Records 
Public Health Reports  2009;124(Suppl 2):24-30.
SYNOPSIS
Objective
We assessed the relationship between Chlamydia trachomatis (CT) infections identified during pregnancy and adverse perinatal birth outcomes (including premature rupture of membranes, preterm delivery, and low birthweight) by matching CT reports and birth records.
Methods
We merged California birth records from 1997, 1998, and 1999 with California CT reports from the same years to determine the proportion of birth records matched to a female CT report, using maternal last name, first name, date of birth, and county of residence. We used logistic regression to assess the crude and adjusted association between a CT report less than 10 months before the birth record date and premature rupture of membranes, preterm delivery, and low birthweight. These results were adjusted for age, race/ethnicity, level of education, and prenatal care.
Results
Of 675,786 birth records and 101,296 female CT reports, 14,039 women had a CT case report and a birth record; 10,917 birth records (1.6%) were matched to a CT report during pregnancy, and 10,940 (10.8%) of CT reports were matched to a birth record date 10 months after date of diagnosis/report. For premature rupture of membranes, the adjusted odds ratio (AOR) was 1.2, 95% confidence interval (CI) 1.0, 1.3; for low birthweight, the AOR was 1.2, 95% CI 1.1, 1.3. The reduction in birthweight associated with prenatal CT infection was 31.7 grams.
Conclusions
The increased risk of adverse perinatal outcomes associated with prenatal CT infection supports current prenatal CT screening guidelines. Matching of surveillance and vital statistics data sources was an efficient method to assess this association.
PMCID: PMC2775397

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