The Launch of the iCoDE Standard Project.

INTRODUCTION: The first meeting of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) project, organized by Diabetes Technology Society, took place virtually on January 27, 2022. METHODS: Clinicians, government officials, data aggregators, attorneys, and standards experts spoke in panels and breakout groups. Three themes were covered: 1) why digital health data integration into the electronic health record (EHR) is needed, 2) what integrated continuously monitored glucose data will look like, and 3) how this process can be achieved in a way that will satisfy clinicians, healthcare organizations, and regulatory experts. RESULTS: The meeting themes were addressed within eight sessions: 1) What Do Inpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 2) What Do Outpatient Clinicians Want to See With Integration of CGM Data into the EHR?, 3) Why Are Data Standards and Guidances Useful?, 4) What Value Can Data Integration Services Add?, 5) What Are Examples of Successful Integration?, 6) Which Privacy, Security, and Regulatory Issues Must Be Addressed to Integrate CGM Data into the EHR?, 7) Breakout Group Discussions, and 8) Presentation of Breakout Group Ideas. CONCLUSIONS: Creation of data standards and workflow guidance are necessary components of the Integration of Continuous Glucose Monitor Data into the Electronic Health Record (iCoDE) standard project. This meeting, which launched iCoDE, will be followed by a set of working group meetings intended to create the needed standard.

Survey of Physician Perspective towards Management of Pain for Chronic Conditions in the Emergency Department.

Sickle cell disease (SCD) pain is often acute-on-chronic, likening it to other chronic acute-on-chronic pain conditions. Pain treatment of SCD was already reported as inadequate prior to the current opioid epidemic, but attitudes underlying treatment were understudied. Understanding these attitudes prior to the current epidemic would be revealing. Therefore in 1997, before the current opioid epidemic, we surveyed physicians' attitudes toward pain management and treatment preferences for acute pain exacerbations in the Emergency Department in SCD versus those of chronic pancreatitis and chronic low back pain, two other acute-on-chronic pain diseases. Thirty-nine residency trainees were surveyed in a level one triage hospital. Resident estimates of the rate of opioid addiction in SCD were higher than estimates in both chronic pancreatitis and chronic low back pain. Most residents relied on their personal clinical experience rather than external sources of data or knowledge as the most important driver when they managed chronic pain. This survey research shows that, predating the current opioid epidemic, there was both a backdrop of opioid-phobia and a bias against treating SCD pain compared to other chronic pain conditions among our sample. Repeating this survey research among current training physicians, along with surveys of other attitudes, would provide useful comparisons.

Immunomodulatory effects of Pimpinella anisum L. (Aniseed) in Broiler Chicks against Newcastle disease and infectious bursal disease viruses / Efecto inmunomodulador de Pimpinella anisum L. (anís) en pollos de engorde contra la enfermedad de Newcastley la enfermedad viral de la bursitis infecciosa

Pimpinella anisum L. (Aniseed) is mostly used as an immune stimulant, growth promoter, antifungal, antibacterial in many countries for centuries. The aim of this study was to determine the immunomodulatory effect of aniseed against Newcastle Disease (ND) and infectious bursal disease (IBD) viruses. The immunomodulatory effect of aniseed against ND and IBD viruses were determined by modifying splenic cell migration inhibition assay and differential leukocyte count for cellular immunity. Haemagglutination inhibition and indirect haemagglutination were used for measurement of humoral immune response against ND and IBD viruses, respectively. The present study suggests that the aniseed addition to basal diet at the rate of 0.5 g/kg and 1 g/kg of feed had best immunomodulatory activity both for humoral and cellular immune responses. However, at higher doses aniseed had adverse effects. Aniseed possesses significant immunomodulatory activity when it is added at lower doses i.e., 0.5 g/kg and 1 g/kg.

Pimpinella anisum L. (Anís) se utiliza principalmente como un estimulante inmunológico, promotor del crecimiento, antifúngico, y antibacteriano, en muchos países durante siglos. El objetivo de este estudio fue determinar el efecto inmunomodulador de anís contra la enfermedad de Newcastle (ND) y la enfermedad de la bursitis infecciosa (IBD). El efecto inmunomodulador de anís contra los virus ND y e IBD se determinaron mediante la modificación del ensayo de inhibición de la migración de células del bazo y recuento diferencial de leucocitos de la inmunidad celular. La inhibición de la hemaglutinación y hemaglutinación indirecta se utilizaron para la medición de la respuesta inmune humoral contra el virus de ND e IBD, respectivamente. El presente estudio sugiere que la adición de anís a la dieta basal a la tasa de 0,5 g/kg y 1 g/kg de alimentación tuvo una mejor actividad inmunomoduladora tanto para las respuestas inmunes humorales como celulares. Sin embargo, a dosis más altas de anís tuvo efectos adversos. El anís posee una importante actividad inmunomoduladora cuando se añade en dosis más bajas, es decir, 0,5 g/kg y 1 g/kg.

Growth promoting effect of Pimpinella anisum (Aniseed) in broiler chickens / Efecto promotor del crecimiento de Pimpinella anisum (semilla de anis) en pollos broiler

The present study was conducted to evaluate growth promoting effect of Pimpinella anisum L. (aniseed) in broiler chickens in terms of body weight gain, organ weights, feed intake and feed conversion ratio (FCR). For this purpose, four levels (0.5, 1.0, 1.5 and 2.0 grams per kg feed) of aniseed powder were administered in feed from day 0 till the end of experiment (42 days of age). The body weight gain, feed intake and FCR were recorded on weekly basis. The birds showed good performance (better weight gain, better feed intake and FCR) when aniseed was fed in lower doses however, birds showed poor performance at higher levels of aniseed. Likewise, almost same pattern was observed for organ weights. This study suggests the good effect of aniseed on performance of broiler chickens at lower doses which suggests the further need of series experiments to find out the minimum safe levels of aniseed to be incorporated in broiler ration to get desirable results.

Se realizó el presente estudio para evaluar el efecto promotor del crecimiento de Pimpinella anisum L. (anís) en pollos de engorde en términos de ganancia de peso corporal, peso de los órganos, el consumo de alimento y conversión alimenticia (FCR). Para este propósito, cuatro niveles (0,5, 1,0, 1,5 y 2,0 gramos por kg de alimento) de anís en polvo se administraron en el pienso desde el día 0 hasta el final del experimento (42 días de edad). La ganancia de peso corporal, consumo de alimento y FCR fueron registrados en forma semanal. Las aves mostraron un buen rendimiento (mejor ganancia de peso, un mejor consumo de alimento y FCR) cuando el anís se alimentó en dosis más bajas, sin embargo, las aves mostraron malos resultados en los niveles más altos de anís. Del mismo modo, se observó casi el mismo patrón de peso de los órganos. Este estudio sugiere que el buen efecto del anís en el rendimiento de pollos de engorde en dosis más bajas que sugiere la necesidad adicional de experimentos de la serie para conocer los niveles de seguridad mínimos de anís que se incorporarán en la ración de pollos de engorde para obtener los resultados deseados.

Teleoncology: improving patient outcome through coordinated care.

INTRODUCTION: There are few specialized oncology centers in Pakistan. Teleoncology was introduced for weekly tumor case meetings between the surgery departments of Holy Family Hospital and NORI Hospital using videoconferencing. The team of surgeons, radiologists, and histopathologists of Holy Family Hospital and the oncologists from NORI Hospital are now conducting joint regular multidisciplinary meetings weekly for the well-being of patients of the area. The purpose of this study is to describe the infrastructure, consultative process, technical aspects, and initial evaluation of these meetings. MATERIALS AND METHODS: The surgical oncology patients are discussed every Friday morning since November 2009. A standardized format was adopted for case discussion in these multidisciplinary meetings. The postgraduate trainee presents the case from either side followed by management plan discussion. The oncologists may request a discussion to plan an intervention at Holy Family Hospital, or the surgeons at Holy Family Hospital may present a case that would benefit from multidisciplinary skills. RESULTS: In total, 264 patients were discussed. The mean age of the patients was 51±16.2 years. In 43% of the patients, the joint treatment strategy was refined from the initial proposed treatment. Breast and gastrointestinal tract malignancies were the most common cases, followed by endocrine and skin and soft tissue tumors. CONCLUSIONS: Teleoncology services can be extended easily with little addition to existing infrastructure but significantly reduce the stress for families as they deal with this challenging disease. Moreover, they improve the clinical evaluation and management strategies.

Characterization of spontaneous recurrent epileptiform discharges in hippocampal-entorhinal cortical slices prepared from chronic epileptic animals.

Epilepsy, a common neurological disorder, is characterized by the occurrence of spontaneous recurrent epileptiform discharges (SREDs). Acquired epilepsy is associated with long-term neuronal plasticity changes in the hippocampus resulting in the expression of spontaneous recurrent seizures. The purpose of this study is to evaluate and characterize endogenous epileptiform activity in hippocampal-entorhinal cortical (HEC) slices from epileptic animals. This study employed HEC slices isolated from a large series of control and epileptic animals to evaluate and compare the presence, degree and localization of endogenous SREDs using extracellular and whole cell current clamp recordings. Animals were made epileptic using the pilocarpine model of epilepsy. Extracellular field potentials were recorded simultaneously from areas CA1, CA3, dentate gyrus, and entorhinal cortex and whole cell current clamp recordings were obtained from CA3 neurons. All regions from epileptic HEC slices (n=53) expressed SREDs, with an average frequency of 1.3Hz. In contrast, control slices (n=24) did not manifest any SREDs. Epileptic HEC slices demonstrated slow and fast firing patterns of SREDs. Whole cell current clamp recordings from epileptic HEC slices showed that CA3 neurons exhibited paroxysmal depolarizing shifts associated with these SREDs. To our knowledge this is the first significant demonstration of endogenous SREDs in a large series of HEC slices from epileptic animals in comparison to controls. Epileptiform discharges were found to propagate around hippocampal circuits. HEC slices from epileptic animals that manifest SREDs provide a novel model to study in vitro seizure activity in tissue prepared from epileptic animals.

Measuring medical students' orientation toward lifelong learning: a psychometric evaluation.

BACKGROUND: The principle of lifelong learning is pervasive in regulations governing medical education and medical practice; yet, tools to measure lifelong learning are lagging in development. This study evaluates the Jefferson Scale of Physician Lifelong Learning (JeffSPLL) adapted for administration to medical students. METHOD: The Jefferson Scale of Physician Lifelong Learning-Medical Students (JeffSPLL-MS) was administered to 732 medical students in four classes. Factor analysis and t tests were performed to investigate its construct validity. RESULTS: Maximum likelihood factor analysis identified a three-factor solution explaining 46% of total variance. Mean scores of clinical and preclinical students were compared; clinical students scored significantly higher in orientation toward lifelong learning (P < .001). CONCLUSIONS: The JeffSPLL-MS presents findings consistent with key concepts of lifelong learning. Results from use of the JeffSPLL-MS may reliably inform curriculum design and education policy decisions that shape the careers of physicians.

A biomedical sensor system for real-time monitoring of astronauts' physiological parameters during extra-vehicular activities.

OBJECTIVE: To design and test an embedded biomedical sensor system that can monitor astronauts' comprehensive physiological parameters, and provide real-time data display during extra-vehicle activities (EVA) in the space exploration. METHODS: An embedded system was developed with an array of biomedical sensors that can be integrated into the spacesuit. Wired communications were tested for physiological data acquisition and data transmission to a computer mounted on the spacesuit during task performances simulating EVA sessions. RESULTS: The sensor integration, data collection and communication, and the real-time data monitoring were successfully validated in the NASA field tests. CONCLUSIONS: The developed system may work as an embedded system for monitoring health status during long-term space mission.

Design and implementation of a web-based system for intraoperative consultation.

BACKGROUND: With the use of electronic information distribution and telecommunication technologies, surgical teleconsultation is possible as a vehicle for consulting with experts remotely without their physical presence in the operating room (OR). This study evaluated real-time teleconsultation from the OR to remote consultants in the Russian Research Center of Surgery, Moscow, Russia and the Fundeni Clinical Hospital, Bucharest, Romania. METHODS: We evaluated the effectiveness of teleconsultation using a secure website interface where consultants could navigate through multimedia-based electronic documentation of a surgical procedure and identify the anatomic landmarks underlying the need for consultation. Additionally, management of a remote camera view by consultants was evaluated. RESULTS: Fifteen thyroidectomies and parathyroidectomies were studied to confirm by teleconsultation the identity of 22 recurrent laryngeal nerves (RLNs). There was no Internet connectivity interruption or dropped signal, and the bandwidth was consistently greater than 1 Mbps. Consultants spent an average of 6 min to review an average of 35 min of surgical records to identify the 22 RLNs. CONCLUSIONS: This study validated a system for real-time teleconsultation using web-based surgical records. In addition, the ability of the consultant to manage the camera view remotely without interrupting the surgical procedure was confirmed.

Using Bayesian networks and rule-based trending to predict patient status in the intensive care unit.

Multivariate Bayesian models trained with machine learning, in conjunction with rule-based time-series statistical techniques, are explored for the purpose of improving patient monitoring. Three vital sign data streams and known outcomes for 36 intensive care unit (ICU) patients were captured retrospectively and used to train a set of Bayesian net models and to construct time-series models. Models were validated on a reserved dataset from 16 additional patients. Receiver operating characteristic (ROC) curves were calculated. Area under the curve (AUC) was 91% for predicting improving outcome. The model's AUC for predicting declining outcome increased from 70% to 85% when the model was indexed to personalized baselines for each patient. The rule-based trending and alerting system was accurate 100% of the time in alerting a subsequent decline in condition. These techniques promise to improve the monitoring of ICU patients with high-sensitivity alerts, fewer false alarms, and earlier intervention.

Evaluation of a documentation system for airway management training.

INTRODUCTION: Resuscitation science is a dynamic part of healthcare training, with an expanding role for simulation. Historically, performance measurement and documentation relied upon the presence of an instructor, an expensive and potentially inaccurate assessment tradition that tied performance testing to a fixed facility. We hypothesize that an automated system might be developed and validated to document performance in airway management for self assessment in the absence of a human trainer. The system would also store and transmit data to a central registry to document skill acquisition and maintenance. METHODS: Multiple video and pressure inputs captured and documented resuscitation task performance on a readily available standard practice manikin. Bag-valve-mask ventilation (BVM), endotracheal intubation, and ventilation via endotracheal tube (ETT) were studied for accuracy, adequacy, and time. The 12 participants performed each task for 5 repetitions, resulting in 60 total attempts for each skill. RESULTS: Twelve untrained participants performed 3 critical tasks in airway management. Review with the system informed the participant of his/her performance and desired outcome. The system also documented skill performance objectively relative to a standard, recording both successes and failures. Compressed and abstracted performance records populated an average 14-megabyte file size (excluding full motion video). DISCUSSION: This system was successfully used to document student performance of BVM, orotracheal intubation, and ventilation via ETT. The system easily integrates documentation, including text reports, airway pressure readings, still images and videos of task performance. Such digital documentation could guide skill acquisition and quantitatively certify performance with minimal reliance upon an instructor and evaluator.

Objective assessment of training surgical skills using simulated tissue interface with real-time feedback.

OBJECTIVE: We have shown previously that achieving competent performance of basic laparoscopic skills is possible in difficult conditions. We hypothesize that real-time performance feedback adds to the quality of proficiency-based simulator training for performance and forces applied to conventional surgical tools while tying square knots and running suture throws. DESIGN: A silk suture was preplaced on a simulated skin pad to assess incision closure by tying square knots and in separate trials to evaluate closure with the task of placing a running suture. The order of task performance was assigned randomly, and each task was repeated 5 times before switching to the second task. In all, 10 repetitions per task were performed by each student. After completion of the second surgical task, the cycle was repeated to test adaptation and retention of motor-skill capabilities. Half the participants were provided with a graphic display in dial format to indicate applied force. SETTING: Bench-top setup of apparatus was performed in a laboratory at Virginia Commonwealth University, Department of Surgery. PARTICIPANTS: Twelve second-year medical students with no surgical skills background participated in the study. RESULTS: Results from the knot-tying task indicated that the average force exerted on tissue forceps by the left hand in the blinded group who performed simple knots actually increased over repeated trials, as opposed to what was achieved by the group that had real-time feedback of their forces being applied. For the running suture, the task average force exerted on surgical tools by both hands was greater in the blind group relative to those viewing real-time graphic feedbacks of forces generated over repeated trials. CONCLUSION: Inclusion of real-time objective assessment in evaluation of surgical skills minimizes subjective evaluation of performance capabilities. A direct correlation between real-time feedback regarding force exerted and extent of surgical task completion was noted.

A surgical telemedicine clinic in a correctional setting.

The telemedicine network between Virginia Commonwealth University Health System (VCUHS) and the Department of Corrections in Virginia has seen a steady increase in the number of disciplines involved in consultation. Hardware integration and methodologies between VCUHS and correctional facilities were supported by Polycom videoconferencing technology. During consults, a VCUHS-based surgeon was provided with patient records, picture archiving and communication system images, and laboratory data or text reports sent by fax. A registered nurse at the correctional site assisted the surgeon at VCUHS. Electronic stethoscope and dermascope were also used for physical examination of inmates. Preoperative encounters included physical examination and informed consent from video. Electronic scheduling and preoperative orders were issued at the time of consultation. Of the 55 consultations completed this past year, 27 were followed by surgical procedures. In one case, the referral diagnosis was corrected and one case required minor change in diagnosis at an in-person examination on the day of surgery. Twenty patients had postoperative examination by telemedicine, and five of these required a second follow-up telemedicine visit. All patients confirmed their informed consent and acknowledged their surgeon upon first meeting face to face at the hospital. Telemedicine consultation for general surgery is an effective asset and can limit patient transfer.

Telemedicine in extreme conditions: disasters, war, remote sites.

Telemedicine has developed around certain assumptions about connectivity and format. From the pioneer work of Kenneth Bird in the 1970's medical events separated by distance were connected for videoconference interaction [1]. The connection implied well developed telecommunications tools at both ends of the interaction. Telemedicine in its most common manifestations relies upon electronic and professional familiarity plus training with proper technical support. This is true even with Internet telemedicine at the low end of bandwidth. A workable Internet service provider and intact telecommunication services are required at both ends. The assumption of intact, robust telecommunications fails when there is any significant disruption of services, power, or trained people to initiate a telemedicine request. The very nature of disasters whether made by nature, made by fellow humans or in war declarations implies a rupture of the social fabric, a failure of infrastructure. This loss of infrastructure and connection happens at a cruel time when the need for services in health matters is generally very much exacerbated. Extreme remote sites have never had infrastructure and therefore fit into this chapter. Is telemedicine incompatible with support and relief in disasters of remote places? Certainly not. However, telemedicine must adapt to the situation in ways not generally associated with standard telemedicine. New solutions can meet the expectation of being wherever services are need whenever the need arises. This chapter looks at the experiences, successes and failures of telemedicine in natural disaster, war, and extreme remote sites. The presentation is concluded with recommendations to make telemedicine integral to any disaster response and a natural tool for any human endeavor that requires sending people to remote and hostile environments.

The authority and utility of Internet information.

Internet use for health information by both practitioners and consumers continues to expand geometrically. The impact of Internet on practice, access and health decisions is considerable and will probably grow to the predominant mode of health information delivery in the coming years. As the growth of this unregulated global bulletin board continues, how do we assure the quality of the information retrieved by professionals and patients? What are the indicators of quality? How should we measure impact? How do authoritative sources get the attention and who should decide? What should practitioners recommend? What should medical teachers advise trainees? This review of Internet content, access and application considers the history, patterns of use, evaluation studies and specialty examples. A few authoritative sources are recommended and that recommendation is justified. Changes in health care delivery must take best advantage of the Internet with least disruption to the important principles of practice and patient relationships. The health community needs effective interaction with medicine's inevitable partner, the Internet.

Remote video management for intraoperative consultation and surgical telepresence.

Telemedicine applications can connect surgeons from one operating room (OR) to a distant consultant. The additional capacity of telepresence provides remote consultants the ability to control their own view of the surgical field using robotic management of a network camera. The goal of this study was to compare access to surgical field by robotic camera versus image controlled by the surgeon using a camera mounted to the table. A Stryker laparoscopic camera was attached to the OR table using a Mediflex arm, and video image was transmitted with a Polycom Transfer Control Protocol (TCP)/Internet Protocol (IP) connection. A network Sony camera was mounted on a tripod, connected over the Internet using a parallel TCP/IP connection. A Web interface allowed control of the camera angle and zoom. In 22 consultations effective bandwidth was 800 Kbps for the network camera and 1024 Kbps for the Stryker camera. The operation was thyroidectomy and the consultant was either in Moscow, Russia, or Bucharest, Romania. The quality of the image in both methods was indiscernible. The ability to identify critical surgical anatomy was also indiscernible. No transmission session failed or had an interruption. The robotic camera can be a powerful tool for surgical collaboration.

Telemedicine licensure in the United States: the need for a cooperative regional approach.

The extraordinary successes and refinement of modern telemedicine applications in recent years have been diminished somewhat by the anachronistic licensure laws of the 50 state jurisdictions that limit the practice of medicine to specific state geographic boundaries. This approach is deficient when applied to telemedicine because, with the advent of the Internet and modern technological advances, differences in space and time are rendered nearly meaningless. It is recommended in this paper that the practice of telemedicine be handled differently than the practice of face-to-face medicine, as related to licensure. Although it may be argued persuasively that a national licensure model for telemedicine should be advanced, the political and constitutional hurdles may be too great to overcome. It is therefore recommended that a voluntary, regional geographic approach be instituted by jurisdictions already demonstrating a commonality of interests, such as through the Southern Governors' Association or the Western Governors' Association. The benefits to be derived from this approach would include improving access to healthcare and medical specialists, enhancing the quality and timeliness of care, cutting medical costs by moving information instead of people, securing patients' access to medical records and information, and facilitating commercial export of American telemedicine services.

Virtual reality laparoscopic skill assessment in microgravity.

BACKGROUND: The objective of the study was to assess if performance of basic laparoscopic skills on a virtual reality (VR) simulator is impaired in microgravity relative to normal gravitational influences. MATERIALS AND METHODS: Fourteen subjects with various educational backgrounds underwent basic laparoscopy skill training for five consecutive days on the ground before flying aboard NASA's KC-135 zero-gravity laboratory. The participants performed basic laparoscopic exercises (clip applying, grasping, cutting, and suturing) on a VR laparoscopy simulator, both on the ground and during 25-s microgravity windows in parabolic flight. Skill levels after ground training were compared with skill levels in performing the same tasks in microgravity. Blinded reviewers measured the number of tasks successfully completed, tissue damage number, left and right hand path lengths during task execution, and percentage of task attempts that resulted in successful completion. RESULTS: A significant increase in tissue injury (t test, P < 0.05) and task erosion were seen in clip applying, cutting, and grasping in microgravity (45%, 20% and 57% decrease in task attempts that resulted in a successful completion, respectively). However, there was no significant difference in the left and right hand path lengths, and the total number of tasks successfully completed on the ground versus in microgravity, for any of the four laparoscopic exercises (t test, P > 0.05). CONCLUSION: This study demonstrates decreased efficiency and increased injury to the simulated tissues in performing laparoscopic skills during microgravity as compared to performing these skills in standard gravitational influence. Additional experiments are indicated to further develop and validate VR microgravity surgical simulation.

Integration of information technology, wireless networks, and personal digital assistants for triage and casualty.

The purpose of this study was to evaluate a portable tool for use by first responders in documenting triage of victims in a mass casualty incident (MCI) more effectively. The tool presented in this study allows first responders to gather patients vital signs, injuries, and triage status in a prompt and accurate way, and enables first responders to wirelessly communicate vital health information throughout the entire care continuum. The architecture infrastructure for the portable device is called Triage and Casualty Informatics Technology (TACIT) and can expedite triage, transport and treatment procedures within an MCI. TACIT was developed by integrating handheld devices, wireless networks, global positioning system (GPS), digital cameras, and bar code scanners with customized triage software. Two MCI initial field trials verified that the TACIT software, battery life, data accuracy, and wireless transmission met the emergency response system requirements. Initial field trials also demonstrated robustness of operation, reduced triage collection time and improved collection accuracy. The TACIT system could work as an efficient prehospital response tool and platform.