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(Poly)phenols and, specifically, phlorotannins present in brown seaweeds have previously been shown to inhibit α-amylase and α-glucosidase, key enzymes involved in the breakdown and intestinal absorption of carbohydrates. Related to this are observations of modulation of post-prandial glycemic response in mice and increased insulin sensitivity in humans when supplemented with seaweed extract. However, no studies to date have explored the effect of seaweed extract on cognition. The current randomized, placebo-controlled, double-blind, parallel groups study examined the impact of a brown seaweed extract on cognitive function post-prandially in 60 healthy adults (N = 30 per group). Computerized measures of episodic memory, attention and subjective state were completed at baseline and 5 times at 40 min intervals over a 3 h period following lunch, with either seaweed or placebo consumed 30 min prior to lunch. Analysis was conducted with linear mixed models controlling for baseline. Seaweed led to significant improvements to accuracy on digit vigilance (p = 0.035) and choice reaction time (p = 0.043) tasks. These findings provide the first evidence for modulation of cognition with seaweed extract. In order to explore the mechanism underlying these effects, future research should examine effects on cognition in parallel with blood glucose and insulin responses.

Objective. To determine the effect of patients’ place of residence on their evaluations of care, and to explore related policy implications. Study Design. We used a conditional regression analysis of stratum matched case controls to examine whether place of residence of patients living in the Greater Toronto Area (GTA) or in Ontario outside of the GTA affects patient satisfaction with their experiences during hospitalization. Setting. One hundred and six acute care hospitals located in the province of Ontario, Canada. Participants. A total of 101 683 Ontario residents hospitalized as inpatients between 1 October 2002 and 30 June 2004. Main Outcome Measures. Patient satisfaction indicators publicly reported in Ontario comprising patient perceptions of consideration, responsiveness, communication, and overall impressions, scored on a continuous scale from 1 to 100. Results. Patients who lived outside Toronto were consistently more satisfied than patients who lived inside Toronto when both types of patients were hospitalized in Toronto (P , 0.0001). In contrast, patients who lived inside Toronto were usually and substantially more satisfied than patients who lived outside Toronto when they were hospitalized in facilities outside Toronto (P , 0.02). These findings were consistent after adjustment for several patient-level predictor variables: age, sex, selfassessed health status and number of hospital stays in the last 6 months. Conclusion. Findings suggest that where patients live has a small but potentially important impact on how they rate their care. Residence may therefore be considered when designing public reporting systems and pay-for-performance programs. Further attention to patient-level factors may be important to accurate and useful public reporting of patient satisfaction.

Background Methods to measure or quantify equity in health care remain scarce, if not difficult to interpret. A novel method to measure health equity is presented, applied to gender health equity, and illustrated with an example of timing of angiography in patients following a hospital admission for an acute coronary syndrome. Methods Linked administrative hospital discharge and survey data was used to identify a retrospective cohort of patients hospitalized with Acute Coronary Syndrome (ACS) between 2002 and 2008 who also responded to the Canadian Community Health Survey (CCHS), was analyzed using decision trees to determine whether gender impacted the delay to angiography following an ACS. Results Defining a delay to angiography as 1 day or more, resulted in a non-significant difference in an equity score of 0.14 for women and 0.12 for men, where 0 and 1 represents perfect equity and inequity respectively. Using 2 and 3 day delays as a secondary outcome resulted in women and men producing scores of 0.19 and 0.17 for a 2 day delay and 0.22 and 0.23 for a 3 day delay. Conclusions A technique developed expressly for measuring equity suggests that men and women in Ontario receive equitable care in access to angiography with respect to timeliness following an ACS.

Background: The goal of this study was to identify aspects of care (predictors) that can most easily be modified to produce an improvement in the score of patients' overall evaluations of the quality of care received. Patients and methods: Our sample consisted of 2247 cancer patients hospitalized in Ontario acute care hospitals in 1999/2000. We sought predictors of patients' overall perceptions of the quality of care by applying a methodology that minimizes the improvement of the predictors while gaining a desired increase in the score of the dependent variable. This approach tends to ignore items that rate relatively high and focuses on those for which hospitals can more easily modify the score. Two main subgroups were analyzed in this study: patients with malignant and benign neoplasms. Results: ‘Skills of nursing staff’, ‘courtesy of nursing staff’, ‘courtesy of people who drew blood’ and ‘cleanliness of hospital in general’ were consistently selected by our approach in both cancer groups. Conclusions: This study identifies an efficient approach to improving the score of patients' overall perceptions of the quality of care received. By focusing on these aspects of care, hospitals may be able to improve the allocation of scarce resources when planning patient satisfaction improvement initiatives.

Study objective Patient satisfaction is an important performance measure for emergency departments (EDs), but the most efficient ways of improving satisfaction are unclear. This study uses optimization techniques to identify the best possible combination of predictors of overall patient satisfaction to help guide improvement efforts. Methods The results of a satisfaction survey from 20,500 patients who visited 123 EDs were used to develop ordinal logistic regression models for overall quality of care, overall medical treatment, willingness to recommend the ED to others, and willingness to return to the same ED. Originally, 68,981 surveys were mailed, and 20,916 were returned, representing an overall response rate of 30.3%. We then incorporated these regressions into an optimization model to select the most efficient combination of predictors necessary to increase the 4 overall satisfaction measures by 5%. A sensitivity analysis was also conducted to explore differences across hospital peer groups and regions. Results Results differ slightly for each of the 4 overall satisfaction measures. However, 4 predictors were common to all of these measures: "perceived waiting time to receive treatment," "courtesy of the nursing staff," "courtesy of the physicians," and "thoroughness of the physicians." The selected predictors were not necessarily the strongest predictors identified through regression models. The optimization model suggests that most of these predictors must be improved by 15% to increase the overall satisfaction measures by 5%. Conclusion This study introduces the use of optimization techniques to study ED patient satisfaction and highlights an opportunity to apply this technique to widely collected data to help inform hospitals' improvement strategies. The results suggest that hospitals should focus most of their improvement efforts on the 4 predictors mentioned above.

Background: The relative risk of diabetes among patients undergoing risperidone treatment was compared with that of patients receiving olanzapine. Method: A cohort was formed of 33,946 patients with at least I prescription for either olanzapine (N = 19,153) or risperidone (N = 14,793) between January 1, 1997, and December 31, 1999, recorded in the Regie de l'Assurance Maladie du Quebec database. Patients were excluded if clozapine was dispensed to them during the study period or if they were diagnosed with diabetes before beginning antipsychotic therapy. New diabetes diagnoses made after the first antipsychotic prescription during the period were tabulated until December 31, 1999; censoring occurred at this date or at the last service date, if there was no record of using services during the last 6 months of follow-up. Crude hazard ratio and proportional hazard analyses were carried out. Results: 319 patients developed diabetes on olanzapine treatment, and 217 developed diabetes on risperidone treatment; a crude hazard ratio of 1.08 (95% CI = 0.89 to 1.31, p = .43) was determined. When age, gender, and haloperidol use were controlled for using proportional hazard analysis, there was a 20% increased risk of diabetes with olanzapine relative to risperidone (95% CI = 0% to 43%, p = .05). Proportional hazard analyses adjusted for duration of olanzapine exposure indicated that the first 3 months of olanzapine treatment was associated with an increased risk of diabetes of 90% (95% CI = 40% to 157%, p

The objective of this study was to develop and validate a simple clinical index to identify individuals at increased risk of an elevated CHL/HDL ratio. Using recursive partitioning, factors associated with an elevated CHL/HDL ratio were identified among 1993 men and 1631 women in the Lipid Research Clinic Prevalence Study. These factors were weighted using logistic regression analyses to develop a clinical index that was validated on 486 men and 484 women reported in the Sante Quebec cardiovascular health survey. A high CHL/HDL ratio was defined as ≥5 for women and ≥6 for men which approximates the 75th percentiles reported in the second United States National Health and Nutrition Survey. In the Lipid Research Clinics cohort, 307 men (15.4%) and 188 women (11.5%) had an elevated CHL/HDL ratio. Using separate clinical indices for men and women, significant variables included body mass index, alcohol consumption, age, smoking status, systolic blood pressure, physical activity status, and the presence of diabetes, the study identified 88% of the men and 82% of the women with elevated ratios. External validation using the Sante Quebec data set demonstrated test sensitivities of 81% for men and 94% for women. Overall, 12% of those with a high CHL/HDL ratio were misclassified as low risk. The ratio of total plasma cholesterol to HDL cholesterol has been shown to be one of the best lipid predictors of increased coronary risk. Readily available clinical data can be used to identify 88% of those individuals most likely to benefit from lipid screening while obviating the need for such screening in one quarter of otherwise healthy adults.

Purpose: To describe the factors predicting waiting time for radiation treatment in early breast cancer. Materials and Methods: Between January 1992 and December 1993, 739 patients with Stage I and II breast cancer were treated with conservative treatment at three McGill University Hospitals. Waiting time was defined as the interval between the date of surgery and the date of the first radiation treatment. Delay was defined as a waiting time of more than 7 weeks for women who did not receive chemotherapy (Group NC, n = 478), and as a waiting time of more than 24 weeks for those who received chemotherapy (Group C, n = 261). We analyzed predictive factors related to the patient (age, stage, treatment on protocol, income by postal code) and to the referring hospital (university or community hospital). Results: For the entire population, 54% of patients were delayed, 72% in Group NC and 21.4% in Group C. Univariate analysis showed an impact of referring hospital in both groups, and of stage and treatment on protocol in Group C (all p = 0.001). Multivariate analysis showed that delays were significantly less in Group NC for women referred from a community hospital ( p = 0.001) and in Group C for women with Stage I disease ( p = 0.06), those treated on protocol, and those referred from a university hospital ( p = 0.001). Conclusion: More than half of patients with early breast cancer waited more than the recommended intervals for radiation therapy. However, lower income breast cancer patients did not wait longer for treatment than higher income patients, possibly a result of the Canadian Medicare system which provides universal access to health care.

A multicenter placebo-controlled trial of early short-term high-dose methylprednisolone enrolled 78 patients with moderate to severe Pneumocystis carinii pneumonia (PCP) complicating HIV infection. The mean pressure of oxygen (PO2) at study entry was 55 mm Hg for the 71 patients who had blood gases monitored while breathing room air. Patients were randomized to receive methylprednisolone (40 mg) or placebo parenterally twice daily for 10 days, and the first dose of study medication was given within 24 h of the first dose of antimicrobial therapy for PCP. The primary end point included death, need for mechanical ventilation for > 6 days, or a partial PO2 < 70 mm Hg while breathing room air 10 days after initiation of treatment. There was no statistically significant difference in the primary end point between patients randomized to corticosteroid (CS) or placebo (PL) (p = 0.522; 95% CI = -0.30, 0.16). The incidence of superinfections during therapy or of other HIV-associated infections or malignancies in the 6 months following treatment for PCP was not significantly different between the two groups. More patients randomized to placebo had to discontinue treatment with trimethoprim-sulfamethoxazole because of hypersensitivity than those randomized to corticosteroids (p = 0.039). We conclude that addition of corticosteroids does not significantly affect the outcome of PCP in patients with HIV and a PO2 < 70 mm Hg on room air at presentation but lowers the incidence of hypersensitivity reactions to trimethoprim-sulfamethoxazole.

The prognostic markers in 87 consecutive patients with lupus nephritis who underwent renal biopsy are reported for five clinically relevant long-term outcomes--renal insufficiency, renal failure, death due to renal systemic lupus erythematosus, death due to non-renal SLE and death due to SLE, both renal and non-renal. We have demonstrated that a number of previously neglected or rarely studied predictors were important prognostic markers. These included the duration of renal disease before biopsy, overall severity of SLE, as well as the presence of vasculitis, hypertension or a comorbid ailment. Furthermore, the study confirms the predictive importance of serum creatinine, 24-h urinary excretion of protein, C3, and of the activity and chronicity indices on biopsy. However, overall a simple measure of tubulointerstitial disease was the best predictor obtained from biopsy. Prognostic models based on clinical data alone were developed for each of the five outcomes. The models amplify our clinical understanding of lupus nephritis. Markers of renal severity were most important in predicting renal outcomes such as renal insufficiency and renal failure. Prognostic factors less directly related to renal disease (comorbidity and vasculitis) were important predictors of fatality. A marker of immunologic disease activity (C3) was a valuable predictor for many of the outcomes. Thus markers of disease severity reflecting organ damage due to SLE and other comorbid conditions could be combined with markers of immunologic activity to predict a variety of outcomes of relevance to a clinician. When biopsy data obtained by light or electron microscopy were evaluated for their ability to add new predictive information to the clinical models, only a limited value for biopsy was noted. It is likely that this reflected the close correlational relationships between clinical and biopsy variables, the strong clinical models generated, and the inclusion in the clinical models of the previously neglected clinical variables, duration of renal disease before biopsy and the presence of vasculitis or comorbid disease.