Research Briefs

Research Activities, April 2010, No. 356

Aujesky, D., McCausland, J.B., Whittle, J., and others (2009, November). "Reasons why emergency department providers do not rely on the pneumonia severity index to determine the initial site of treatment for patients with pneumonia." (AHRQ grant HS10049). Clinical Infectious Diseases 49, pp. e100-e108.

Community-acquired pneumonia (CAP) causes 4 million cases of illness and leads to more than 1 million hospital admissions in the U.S. every year. Evidence suggests that physicians tend to overestimate the risk of death among patients with CAP and these overestimates are associated with the decision to hospitalize low-risk patients. The researchers conducted a trial to implement a Pneumonia Severity Index (PSI) guideline for the initial site of treatment of patients with CAP. They used data on 1,306 patients (689 were low-risk and 617 higher-risk) from 12 emergency departments (EDs) in two states. ED physicians admitted 37.4 percent of low-risk patients to the hospital while treating 3.2 percent of higher-risk patients on an outpatient basis. The reasons given by ED physicians for admitting low-risk patients included presence of another illness (71.5 percent); abnormal laboratory values, vital signs, or symptoms (29.3 percent); and recommendation for admission from a primary care or consulting physician (19.3 percent).

Barr, W. B., Bender, H. A., Morison, C., and others (2009). "Diagnostic validity of a neuropsychological test battery for Hispanic patients with epilepsy." (AHRQ grant HS16819). Epilepsy & Behavior 16, pp. 479-483.

The Neuropsychological Screening Battery for Hispanics (NeSBHIS) is sensitive to cognitive impairments commonly observed in populations with epilepsy, but it is limited in its ability to identify lateralized neuropsychological impairment in patients with temporal lobe epilepsy, concludes this study. The researchers sought to examine the diagnostic validity of the NeSBHIS in identifying relevant cognitive impairment in Spanish-speaking Hispanic patients with epilepsy and in predicting seizure lateralization in surgical candidates. Their final study sample included 115 Hispanic patients with epilepsy who had completed neuropsychological evaluations. Decreased scores on tests of naming and processing speed were identified in more than 40 percent of the sample and 30 percent of the subjects had low scores on memory testing. Deficits in verbal and visual recall were exhibited by 29 and 26 percent of the sample, respectively. The study failed to find any marked difference in neuropsychological test performance on group comparisons made in 82 patients with EEG evidence of partial seizures located to the left or right temporal lobes.

Beckett, M. K., Elliott, M. N., Richardson, A., and others. (2009, October). "Outpatient satisfaction: The role of nominal versus perceived communication."(AHRQ grant HS13299) HSR: Health Services Research 44(5 Part I), pp. 1735-1749.

Attempts to correlate successful parent-pediatrician communications with parent satisfaction are limited by differences in reports from parents and from trained observers, a recent study found. Parents were also asked to rate the child's care based on the current pediatrician visit (six choices, ranging from "excellent" to "very poor"). The researchers analyzed 517 encounters involving 38 pediatricians in 27 community pediatric practices in Los Angeles County, Calif. All of the visits were for children, aged 6 months to 10 years, seen for upper respiratory tract infections. The four communication events compared between parent report and coder report of the pediatrician visit were discussion of: (1) the child's symptoms; (2) what the parents could do to make the child feel better; (3) the parent's ideas about the cause of the child's illness; and (4) the parent's ideas about how to manage the child's illness. Each visit was videotaped and communication events were coded by one of two trained research assistants. For all four communication events, parent and coder assessments were uncorrelated. Parent perception of three or four of the communication events occurring was correlated with greater satisfaction, but any coded events not reported by parents did not contribute to parental satisfaction.

Casale, C. R. and Clancy, C. M. (2009). "Commentary: Not about us without us." Academic Medicine 84(10), pp. 1333-1335. Reprints (AHRQ Publication No. 10-R022) are available from the AHRQ Publications Clearinghouse

Solutions to eliminate disparities in health care must be customized to address the specific circumstances of each community. Community-based participatory research (CBPR) offers an appealing strategy to develop the requisite evidence while care is being improved. These authors comment on an article in the same issue of the journal that presents case studies from the University of California Los Angeles' CBPR experience with minorities in the Sun Valley area of Los Angeles County. They believe that the UCLA-Sun Valley experience highlights the importance of partnering with community leaders and residents in all aspects of the research process. This includes discovery, planning, development, implementation, and evaluation of a research proposal, as well as research dissemination and adoption activities. The authors offer insights for community leaders, researchers, and funders such as the importance of training and education for community leaders and residents and the inclusion of CBPR in medical school curricula.

Castaldi, P. J., DeMeo, D. L., Kent, D. M., and others (2009, October). "Development of predictive models for airflow obstruction in alpha-1-antitrypsin deficiency." (AHRQ grant T32 HS00060) American Journal of Epidemiology 170(8), pp. 1005-1013.

In this paper, researchers identified characteristics of patients with a genetic inability to synthesize the enzyme inhibitor alpha-1-antitrypsin, who are likely to develop respiratory problems, such as chronic obstructive pulmonary disease (COPD). The researchers used two approaches to create predictive models, one for predicting the volume of air exhaled from the lungs in 1 second and the other for predicting the presence of severe COPD. Predictive factors in both models included the patient's age, sex, a measure of the patient's smoking intensity and length of time he or she smoked, the patient's responsiveness to medicines for bronchitis (bronchodilators), and whether the patient had symptoms of chronic bronchitis. The presence of certain markers in the genes for two inflammation-related proteins (interleukin-10 and tumor necrosis factor) appeared to improve the predictive ability of the models slightly. The models were based on data collected on 372 individuals from 167 families from 2002 through 2005.

Cegala, D. J. and Post, D. M. (2009). "The impact of patients' participation on physicians' patient-centered communication." (AHRQ grant HS90110). Patient Education and Counseling 77, pp. 202-208.

The concepts of patient-centered communication and patient participation are central to current views of the ideal physician-patient relationship. Even so, little attention has been given to the interplay of physicians' and patients' communication. The researchers studied 25 physicians who interacted with both high- and low- participation patients. High participation was related to the frequency of information seeking/verifying, information provision, assertive utterances, and expressed concerns. On one dimension of patient-centeredness, exploring both the disease and illness, the high-participation patients evoked more communication from their physicians, but on the other two dimensions (understanding the whole person, finding common ground) there were no significant differences in communication from physicians of high- or low-participation patients. One explanation for the lack of difference on the dimension of "understanding the whole person" is that around 80 percent of both high- and low- participation patients were return patients.

Chapman, B. P., Franks, P., Duberstein, P. R., and Jerant, A. (2009). "Differences between individual and societal health state valuations. Any link with personality?" (AHRQ grant HS13603). Medical Care 47(8), pp. 902-907.

Health status measures may be based on community or societal preferences for some health states over others (as measured by the EuroQoL-5D, a preference-based health status measure used across patient groups) or they may be based simply on an individual's opinion (as measured by the EuroQol Visual Analogue Scale, a companion health status measure). These researchers investigated the role of personality in contributing to these differences by using the Five Factor Model personality traits of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. The 370 patients studied all had a chronic disease accompanied by a basic activity impairment and/or depression. Higher levels of conscientiousness appeared to be the principal personality factor responsible for persons reporting less disutility from poor health states than the societal valuations used in reference case analysis. In fact, social preference measures may undervalue the health states of more conscientious individuals, suggest the researchers.

Chibnall, J. T. and Tait, R. C. (2009). "Long-term adjustment to work-related low back pain: Associations with socio-demographics, claim processes, and post-settlement adjustment." (AHRQ grants HS13087 and HS14007). Pain Medicine 10(8), pp. 1378-1388.

This study investigated sociodemographic, claim process, and short-term adjustment predictors of long-term (6 years post-settlement) clinical adjustment among Workers Compensation claimants with low back pain (171 blacks and 203 whites). Poorer long-term adjustment (higher levels of pain, catastrophizing, and pain-related disability) was significantly predicted by relatively poorer adjustment at baseline, lower socioeconomic status, and black race. Pain intensity, catastrophizing, and interference with role functioning assessed 6 years after claim closure were comparable with those assessed more than 4 years earlier (at baseline). The associations of race were somewhat attenuated 6 years after claim settlement, whereas the significance of the socioeconomic status association remained, although at a somewhat reduced magnitude.

Clancy, C. M. (2009, November). "Tools to alleviate safety concerns." Trustee Magazine November 2009. Reprints (AHRQ Publication No. 10-R028) are available from the AHRQ Publications Clearinghouse

As stewards of America's hospitals, trustees have the moral imperative and leverage to drive patient safety and quality improvements. The author, Director of the Agency for Healthcare Research and Quality (AHRQ), offers four pieces of advice that, in conjunction with implementing AHRQ toolkits and using AHRQ resources, can help hospitals navigate patient safety challenges: (1) view safety, quality, and financial goals as interdependent; (2) advocate for a culture of safety; (3) consider safety and quality when making major capital investments; and 4) facilitate transitions between the hospital and other health care settings. The author next describes several of AHRQ's key patient safety tools: the Hospital Survey on Patient Safety Culture; the Hospital Consumer Assessment of Healthcare Providers and Systems; Inpatient Quality Indicators; and Project RED (Re-engineered Hospital Discharge). Also available from AHRQ is a DVD on "Transforming Hospitals: Designing for Safety and Quality," which makes the case that evidence-based design results in a positive return on investment. The author encourages trustees to partner with AHRQ to use these tools to provide Americans with high-quality care.

Clancy, C. M. (2009, December). "Where we are a decade after To Err is Human." Journal of Patient Safety 5(4), pp. 199-200. Reprints (AHRQ Publication No. 10-R029) are available from the AHRQ Publications Clearinghouse

A decade ago, the Institute of Medicine's report, To Err is Human: Building a Safer Health System, emphasized that medical harm results from the systemic problems in health care. Despite the challenges, some organizations have improved their culture, communications, and teamwork. The Agency for Healthcare Research and Quality (AHRQ), along with others, has been making progress on building an evidence-based foundation and tools to make it easier for organizations to reduce medical harm. One example of this is in the reporting of adverse events. Today, more than half of the States have instituted mandatory reporting of serious events. During the past decade, AHRQ has been working to discover the causes of preventable errors. It has also been designing, testing, and evaluating evidence-based tools and solutions to reduce errors. This work has focused on creating a culture of safety, encouraging teamwork, reducing hospital-acquired infections (especially methicillin-resistant Staphylococcus aureus), reducing hospital readmissions, and understanding resident fatigue.

Curtis, J. R., Taylor, A. J., Matthews, R. S., and others (2009). "Pathologic fractures: Should these be included in epidemiologic studies of osteoporotic fractures?" (AHRQ grant HS16956). Osteoporosis International 20, pp. 1969-1972.

Many studies of the epidemiology and outcomes associated with osteoporotic fracture exclude pathologic fractures. The rationale is that a pathologic fracture is due to a localized process such as a malignancy or an infection and is not related to osteoporosis. However, excluding persons with pathologic fractures in epidemiologic studies that use administrative claims data substantially underestimates the burden of fractures due to osteoporosis, concludes this study. The researchers examined pathologic fractures of the vertebrae and hip in an elderly Medicare population. They identified 44,120 individuals with a vertebral fracture and 60,354 with a hip fracture. Approximately 48 percent of vertebral fractures and 3 percent of hip fractures were coded as pathologic. Evidence for a possible cancer diagnosis was found for 66 percent of those with pathologic hip fracture but for only 25 percent of those with pathologic vertebral fracture.

Denham, C. R., Angood, P., Berwick, D., Clancy, C., and others (2009). "The chasing zero department: Making idealized design a reality"; "Chasing zero: Can reality meet the rhetoric?" Journal of Patient Safety 5(4), pp. 211-215, 216-222. Reprints (AHRQ Publication Nos. 10-R030 and 10-R031) are available from the AHRQ Publications Clearinghouse

Leaders from the quality, purchasing, and certifying sectors of health care convened at a national leadership meeting held in Washington, D.C. in September 2009 to address the issue of hospital-acquired infections (HAIs). The authors of these two papers summarized the meeting and its conclusions. The objective of the meeting was to determine if zero HAIs should be the improvement target for hospitals and what a Chasing Zero Department (CZD) should be like. Participants addressed the key design issues of CZDs: leadership, resources, and systems. They concurred that hospital CEOs and boards must communicate to the organization that the typical Infection Control Group might be restructured into a CZD. Also, funding for these efforts must be provided, with chief financial officers understanding that zero HAIs will preserve revenue. With respect to systems, change can be made through leaders' championship, use of safe practices, and use of the Automated Infection Identification and Mitigation System. The participants agreed that it is possible to get to zero HAIs, that rhetoric can meet the reality of frontline care, and that the national community can recalibrate its expectations of hospitals.

Flores, C. and Newcomer, R. (2009). "Monitoring quality of care in residential care for the elderly: The information challenge." (AHRQ grant HS16541). Journal of Aging and Social Policy 21, pp. 225-242.

The increasing prevalence of physical and cognitive frailty among residential care and assisted living residents provides a compelling public health incentive for a comprehensive residential care/assisted living (RC/AL) data system. The researchers sought to assess the completeness and availability of administrative data compiled on California residential care facilities for the elderly (RCFE). They considered the quality and performance oversight indicators that could be derived from public or other information. After performing a 5-year retrospective review of forms and documents used in 340 California facilities, they found that information from RCFEs, if appropriately compiled and maintained, would produce a comprehensive quality assurance system.

Gallagher, T. H., Cook, A. J., Brenner, R. J., and others (2009, November). "Disclosing harmful mammography errors to patients." (AHRQ grant HS10591). Radiology 253(2), pp. 443-452.

To assess radiologists' attitudes about disclosing harmful mammography errors to patients, the researchers surveyed radiologists at seven geographically distinct Breast Cancer Surveillance Consortium sites. The survey included a hypothetical vignette involving an error interpreting a patient's mammogram. Of the 243 responding radiologists, 9 percent reported that they would "definitely not" disclose the error, 51 percent "only if asked by the patient," 26 percent "probably," and 14 percent "definitely." Neither the level of concern about the effect that malpractice is having on the practice of mammography nor having been sued previously were associated with disclosure willingness or disclosure content. The researchers believe that disclosing errors can educate patients that no one, including their physician, is perfect and that errors happen in all professions, including medicine.

Gray, B. H., Schlesinger, M., Siegfried, S. M., and Horwitz, E. (2009). "Racial and ethnic disparities in the use of high-volume hospitals." (AHRQ grant HS14074). Inquiry 46, pp. 322-338.

This study examined racial and ethnic disparities in the use of high-volume hospitals in the New York metropolitan area during 1995-1996 and 2001-2002. It specifically examined the use of 17 services for which a positive volume-outcome relationship has been documented in previous research: five types of cancer surgery, six cardiovascular services, three orthopedic procedures, two prostate procedures, and admission for AIDS. The researchers found many large racial and ethnic differences in the use of high-volume hospitals for the volume-sensitive services studied. For example, black patients were significantly less likely than white patients to use a high-volume hospital for 16 of 17 services (the exception was AIDS). The same was true for Hispanic patients for 15 of 17 services (the principal exception was AIDS). These disparities were not attributable to differences in socioeconomic status, insurance coverage, or neighborhood of residence.

Hellinger, F. J. (2009, October). "The effect of certificate-of-need laws on hospital beds and healthcare expenditures: An empirical analysis." American Journal of Managed Care 15(10), pp. 737-744. Reprints (AHRQ Publication No. 10-R023) are available from the AHRQ Publications Clearinghouse

Certificate-of-need programs are intended to curtail the construction of unnecessary hospitals and limit the acquisition of costly medical equipment by compelling health care entities to acquire prior approval from a government agency. In 1967, New York became the first State to institute a certificate-of-need program. Since then, all States have created such programs. Some states have repealed their certificate-of-need laws or portions of the laws, and several have dismantled their programs and created new programs later. Currently, 34 States have certificate-of-need laws. This researcher used State-level data at four points in time (1985, 1990, 1995, and 2000) to estimate the effect of certificate-of-need legislation on hospital bed supply and health care expenditures. He found that certificate-of-need laws have reduced the number of hospital beds by about 10 percent and health care spending at the State level by nearly 2 percent. He also found that States with more stringent certificate-of-need programs have experienced greater reductions in the number of hospital beds and health care expenditures.

Kawamoto, K., Honey, A., and Rubin, K. (2009). "The HL7-OMG healthcare services specification project: Motivation, methodology, and deliverables for enabling a semantically interoperable service-oriented architecture for healthcare." (AHRQ grants HS10472, HS15057, HS10814). Journal of the American Medical Informatics Association 16, pp. 874-881.

The health care industry could benefit by realigning its information technology (IT) assets around a service-oriented architecture (SOA) in which business needs are fulfilled through the orchestration of platform-neutral, network-accessible software services that provide core business functions through well-defined interfaces. To address this need, the Healthcare Services Specification Project (HSSP), a joint initiative of a private company and a computer industry consortium, was launched. Its purpose was to generate a comprehensive framework for the specification of standard service interfaces, known as the HSSP Service Specification Framework (SSF). The authors describe the SSF, outline how it has been used to specify two HSSP services, and discuss implications and future directions.

Khoury, J. J., Rich, E. C., Randhawa, G., and others (2009, October). "Comparative effectiveness research and genomic medicine: An evolving partnership for 21st century medicine." Genetics in Medicine 11(10), pp. 707-711. Reprints (AHRQ Publication No. 10-R033) are available from the AHRQ Publications Clearinghouse

Concerns have been raised that evidence-based medicine principles embodied in comparative effectiveness research (CER) are only relevant to "average" patients and not as much to individuals with unique combinations of genes, risks, and disease outcomes intrinsic in genomic medicine (GM). In their commentary, the authors argue that CER and GM not only can and should coexist, but they will also increasingly benefit from each other. The promise and success of GM will depend on rigorous CER methods to compare outcomes for genome-based applications with traditional non-genome-based approaches. The success of CER will depend on developing new approaches and building the capacity to integrate genome-based personalized perspectives into point-of-care decisions by patients and providers.

LaVeist, T. A., Isaac, L. A., and Williams, K. P. (2009, December). "Mistrust of health care organizations is associated with underutilization of health services." (AHRQ grant HS13274). HSR: Health Services Research 44(4), pp. 2093-2105.

There is a lack of empirical research on mistrust in medical care settings and its impact on use of health care services. One problem has been the lack of a generalized measure of mistrust in health care that is suitable for inclusion in both patient-based and community studies. The authors report on the validation of an instrument to measure mistrust of health care organizations. They then use that instrument, the Medical Mistrust Index, a 17-item scale, to examine the relationship between mistrust and racial disparities in use of health care services. After surveying a random sample of 327 persons in Baltimore households, the researchers found that mistrust was associated with greater odds of failing to take medical advice, failing to keep a followup appointment, postponing receiving needed care, and failing to fill a prescription. However, mistrust was not associated with failing to get needed care.

Meyers, D. (2009). "Breastfeeding and health outcomes." Breastfeeding Medicine 4 (Suppl 1), pp. S13-S15. Reprints (Publication No. 10-R034) are available from the AHRQ Publications Clearinghouse

The author summarizes a report published in 2007 on outcomes of breastfeeding on maternal and child health in developed countries, which was prepared for the Agency for Healthcare Research and Quality by the Evidence-Based Practice Center of the Tufts-New England Medical Center. The report summarized evidence on breastfeeding in maternal and child health through May 2006. It concluded that breastfeeding provided short-term benefits, including lower rates for common illnesses such as ear infections and vomiting and diarrhea. Longer-term benefits for breast-fed infants included lower rates of eczema and obesity and decreased rates of serious illnesses such as type 2 diabetes and childhood leukemia. Finally, the evidence indicates that exclusive breastfeeding has greater health benefits than mixed feeding which, in turn, has produced better outcomes than formula feeding.

Pronovost, P. J., Goeschel, C. A., Olsen, K. L., and others (2009). "Reducing health care hazards: Lessons from the commercial aviation safety team." Health Affairs April 7, 2009 Web exclusive, pp. 479-489. Reprints (Publication No. 10-R021) are available from the AHRQ Publications Clearinghouse

The authors contrast the success of the Commercial Aviation Safety Team (CAST), an industry/ government partnership, in reducing fatal aviation accidents with the slow progress made in improving patient safety in health care. They describe how CAST was formed following a fatal plane crash in 1995 and then proceed to outline its organization and procedures. They next point to CAST's record of having completed 48 of 70 safety projects since 1995, almost all without administrative action by the Federal Aviation Administration. By contrast, when the Joint Commission calls for a standard for medication reconciliation to prevent medical errors, it has had limited success. Health care needs a routine mechanism such as CAST in order to develop and broadly implement strong interventions to improve patient safety. This could be called a Public Private Partnership to Promote Patient Safety, suggest the authors. They call on the Agency for Healthcare Research and Quality to be the driving force in creating such a group.

Shaw, S. J., Huebner, C., Armin, J., and others (2009). "The role of culture in health literacy and chronic disease screening and management." (AHRQ grant HS14086). Journal of Immigrant Minority Health 11, pp. 460-467.

Cultural beliefs around health and illness are an integral part of a patient's ability to understand and act on a doctor's instructions. Thus, efforts to improve health literacy that fail to consider these beliefs are unlikely to fully address the needs of those populations suffering from very low health literacy. The authors reviewed social science and medical literature to explore the impact of cultural differences and low health literacy on chronic disease outcomes and use of preventive screening tests. They found that many societies have explanatory models for acute illness conditions that lack an understanding of the idea of chronic disease. With respect to screening utilization, one study reported that stigma associated with "non-normative" sexual behavior may keep unmarried Latinas from seeking out Pap smears. The authors call for well-rounded programs to address cultural and linguistic barriers and low health literacy simultaneously in primary care and prevention settings.

Utter, G. H., Zrelak, P. A., Baron, R., and others (2009). "Positive predictive value of the AHRQ accidental puncture or laceration Patient Safety Indicator." (AHRQ Contract No. 290-04-0020). Annals of Surgery 250(6), pp. 1041-1046.

The National Quality Forum recently endorsed the Agency for Healthcare Research and Quality's Patient Safety Indicator (PSI) 15 on Accidental Puncture or Laceration (APL). To determine the positive predictive validity (PPV) of PSI 15, the researchers conducted a retrospective cross-sectional study of hospitalization records that met criteria for this indicator. They found 249 cases from 32 geographically diverse hospitals that met PSI 15 criteria and 226 of the 249 cases represented true APL. Included among these true positive cases were 56 (25 percent) with "inconsequential" APL that did not require a subsequent visit to the operating room for repair. Another 170 of the cases involved a potentially consequential APL, 132 of which involved some reparative procedure immediately after the occurrence. From the standpoint of clinical relevance, the PPV of PSI 15 was 68 percent.

Vilhauer, R. P. (2009). "Perceived benefits of online support groups for women with metastatic breast cancer." (AHRQ grant HS10565). Women & Health 49, pp. 381-404.

This study examined the helping processes in online groups for women with metastatic breast cancer (MBC) by looking for the presence of therapeutic factors described in earlier research. The six factors theorized to be helpful were: universality, information exchange, instillation of hope, catharsis, altruism, and group cohesiveness. Then 20 white women with MBC, recruited for a larger study, were assigned to one of three online support groups. Each woman was E-mailed a monthly questionnaire and then interviewed for 30-90 minutes after participating in a group for at least 4 months. All six helpful factors mentioned were present in the groups studied. For example, group cohesiveness seems to have benefited women by directly alleviating their anxiety, helping them to get better medical care, reducing their need for social support, and increasing their openness to others.

Yabroff, K. R., Saraiya, M., Mesisner, H. T., and others (2009, November). "Specialty differences in primary care physician reports of Papanicolaou test screening practices: A national survey, 2006-2007." (AHRQ grant HS10565). Annals of Internal Medicine 151(9), pp. 602-611.

Following the substantial revisions to cervical cancer screening guidelines in 2002 and 2003, the researchers used a large, nationally representative sample of primary care physicians to identify current Pap test screening practices in the United States during 2006 to 2007. They used clinical vignettes describing women by age and by sexual and screening history to elicit physicians' recommendations for Pap test screening. Fewer than one-fourth of physicians reported guideline-consistent recommendations for Pap test screening across vignettes. Guideline-consistent recommendations varied by specialty (obstetrics/gynecology, 16.4 percent; internal medicine, 27.5 percent; and family or general practice, 21.1 percent). The researchers conclude that the overuse of Pap test screening revealed by this survey is expensive for the health care system and may result in unnecessary followup testing and increased risk of colposcopy-associated illnesses and adverse birth outcomes.

Current as of April 2010
Internet Citation: Research Briefs: Research Activities, April 2010, No. 356. April 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/newsletters/research-activities/apr10/0410RA43.html