Formative evaluation of a multimedia program for patients about the side effects of cancer treatment.

Formative evaluation of multimedia programs can prevent costly and time-consuming revisions and result in more effective programs. Yet systematic formative evaluation is seldom conducted. This paper reviews the basic principles of formative evaluation and describes how we applied those principles to the formative evaluation of a multimedia program for patients about the side effects of cancer treatment. It discusses the challenges of developing multimedia programs for patients and provides guidance to other health professionals interested in developing programs on other topics.

Behaviour of domestic ducks exposed to mobile predator stimuli. 1. Flock responses.

1. Small flocks of ducks (Anasplatyrhynchos domesticus) were exposed to two stimuli, a small mobile vehicle and a walking human, to investigate their flight responses. 2. Experiment 1. Flocks were herded around an annular arena by each stimulus at 0.5 ms(-1) and the flight distance between the stimulus and the centre of the flock, and individual positions within the flock were recorded every 10 s. Flocks maintained a significantly longer distance from the human (6.0 m) than the vehicle (5.1 m) and usually did not maintain visual contact with either stimulus. Significant consistency in individual positions within the flock was found within and between trials. 3. Experiment 2. Flocks were exposed to each stimulus which approached them as they were feeding in a circular arena. The latencies for cessation and resumption of feeding were recorded and the paths followed by the flocks described. Ducks showed a significantly shorter latency to cease feeding in response to the human (4.9 s) compared with the vehicle (6.9 s). 4. Domestic ducks apparently perceive an approaching human as a greater threat than a small vehicle. The findings are discussed in relation to the development of herding robots.

Behaviour of domestic ducks exposed to mobile predator stimuli. 2. The association of individual duckling attributes with relative position in a flock.

1. We investigated whether an individual duckling's (Anas platyrhynchos domesticus) attributes were associated with its response to an approaching human when it was a member of one of three flocks of 12. 2. Each individual was scored according to its response to (i) an approaching human when alone and feeding, (ii) a taxidermist's model fox when alone and feeding, and (iii) an approaching human when alone in a 9 m annulus, and its nearest neighbour distance in the home pen, competitiveness for food in a series of paired encounters, running ability and physical characteristics. 3. Each flock was herded around a 7 m diameter annulus in separate trials by a human walking at 0.5ms(-1). The distance maintained by each duckling from the human, and hence its relative flock position, was calculated. 4. Individual flight distance maintained from an approaching human when alone in an annulus was the attribute that predicted distance maintained from an approaching human when part of a flock. 5. Some ducklings had reduced average distances from an approaching human when they were in a flock compared to when they were tested alone, and inter-individual variation in distance from the human was greatly reduced when birds were part of a flock.

Partnership for front-line success: a call for a national action agenda on workforce development.

Despite more than a decade of dialogue on the critical needs and challenges in public health workforce development, progress remains slow in implementing recommended actions. A life-long learning system for public health remains elusive. The Centers for Disease Control and Prevention and the Agency for Toxic Substances and Disease Registry in collaboration with other partners in federal, state, local agencies, associations and academia is preparing a national action agenda to address front-line preparedness. Four areas of convergence have emerged regarding: (1) the use of basic and crosscutting public health competencies to develop practice-focused curricula; (2) a framework for certification and credentialing; (3) the need to establish a strong science base for workforce issues; and (4) the acceleration of the use of technology-supported learning in public health.

Comprehensive, technology-based clinical education: the "virtual practicum".

This article discusses the application of technology to promote more comprehensive clinical education in the biopsychosocial aspects of primary care. Comprehensive refers to the inclusion, in addition to scientific and technical knowledge, of knowledge that is less easily characterized, quantified, and taught: empathy, intuition, the demonstration of artistry. Clinical education will be increasingly facilitated by the proliferation of computers capable of displaying combinations of text, graphics, video, and sound; broadband networks capable of delivering these multiple media to the home or office; and new methods for using these technologies for education and training. However, current models for technology-based learning are limiting, lagging behind the rapid technological evolution driving our entry into the Information Age. Some recent educational models (Schon's reflection-in-action and reflective practicums [1], Boisot's E-space [2], Kolb's learning cycle [3]) provide for a more comprehensive and complete view of health professional education. This article describes these models in depth and proposes a new model for technology-based clinical training, the "Virtual Practicum," based on them. The Virtual Practicum is illustrated with a new interactive CD-ROM program, dealing with primary care of patients with HIV/AIDS. The concepts presented here are generally useful in thinking about clinical education, regardless of the means used.

Patient reactions to a program designed to facilitate patient participation in treatment decisions for benign prostatic hyperplasia.

Patients often want considerable information about their conditions, and enhanced patient participation might reduce unwanted practice variation and improve medical decisions. The authors assessed how men with benign prostatic hyperplasia reacted to an education program designed to facilitate participation in decisionmaking, and how strongly ratings of their symptom state and the prospect of complications predicted their treatment choice. A prospective cohort study was conducted in three hospital-based urology practices: two in prepaid group practices, and one Veterans Administration clinic. Four hundred twenty-one men with symptomatic benign prostatic hyperplasia without prior prostatectomy or benign prostatic hyperplasia complications were enrolled, and 373 provided usable ratings. Subjects participated in an interactive videodisc-based shared decisionmaking program about benign prostatic hyperplasia and its treatment options, prostatectomy, and "watchful waiting." They rated the length, clarity, balance, and value of the program and were followed for 3 months to determine if they underwent surgery. Patients rated the program as generally clear, informative, and balanced. Across all three sites, 77% of patients were very positive and 16% were generally positive about the program's usefulness in making a treatment decision. Logistic models predicting choice of surgical treatment documented the independent importance of negative ratings of the current symptom state (odds ratio 7.0, 95% confidence interval 2.9-16.6), as well as the prospect of postoperative sexual dysfunction (odds ratio 0.20, 95% confidence interval 0.08-0.48) in decisionmaking. Patients rated the Shared Decisionmaking Program very positively and made decisions consistent with their assessed preferences. These results suggest that patients can be helped to participate in treatment decisions, and support a randomized trial of the Shared Decisionmaking Program.

Absence of a tachycardic response to shock in penetrating intraperitoneal injury.

The belief that tachycardia is an early and reliable indicator of shock has recently been challenged. We examined 144 battlefield casualties with penetrating intraperitoneal injury to determine whether patients in shock presented with pulse rates that were significantly more rapid than those in patients not in shock. No differences in mean pulse rates were found when using objective operational definitions of shock. In contrast, the only pulse rate difference was noted when shock was defined on the basis of the surgeon's subjective clinical impression and this was attributed to selection bias. The absence of a tachycardic response in battlefield casualties with penetrating abdominal wounds cannot be taken as an indication that serious injury and significant intraperitoneal bleeding have not occurred. Caution should be exercised when using this parameter as a guide for therapeutic interventions, and further study is indicated to determine whether a similar pattern is seen in civilian practice.

Urbanization in a developing country: city size and population composition.

Reasons for the high correlation between city size and educational attainment in developing countries are explored. "Two explanations are examined. First, the types of goods produced in larger cities require relatively high skill labor inputs. Second, public and perhaps private services demanded by higher skill people are only offered in larger cities. The paper econometrically tests these hypotheses for Brazil, estimating the elasticities of substitution (or typically complementarity) between high and low skill labor and the 'bright lights' effect for high versus low skill labor."

Interactive videodisc to teach combat trauma life support.

Training military physicians in trauma management is a dilemma in peacetime, since there are few opportunities to gain clinical experience within the military care system. This program provides experience in clinical decision making through case simulation. Five cases, of increasing difficulty, are presented in a single videodisc side. The program is implemented on a system based on the IBM PC, and is written in the C programming language. The program emphasizes clinical realism by providing many clinical options at each decision point, and by audiovisually depicting combat clinical care in very realistic ways. The user interface is flexible and, though complex, is easy to use; it is supported by a narrated, on-line tutorial.

The importance of operational definitions in design of a combat casualty information system.

Attention to the quality of information in design of a medical information system is fundamental to the success of that system. This point is made using WWI and WWII combat casualty statistics. While the analyses presented are legitimate, serious problems of interpretation arise from the operational definitions used in gathering and analyzing these data. The impact of this is illustrated in a hypothetical battle, a model emphasizing the introduction of biases resulting from an apparent inattention to operational definitions on the part of combat care managers in WWII. The paper concludes with some broad recommendations.

Helium pressure alteration of function in squid giant synapse.

The squid giant synapse, which permits intracellular electrical measurements in a single, excitatory synapse, was exposed to helium pressures up to 204 atm. By stimulating presynaptically and recording postsynaptically with an intracellular electrode it was found that pressure alters, but does not prevent, synaptic transmission of action potentials. Synaptically transmitted action potentials are prolonged in the same way as in the directly stimulated axon. However, slowing of the excitatory postsynaptic potential and marked increases in synaptic fatigue were observed at pressures as low as 35 atm. These changes may contribute to high pressure nervous effects by interfering with information transfer within the nervous system.

Apparatus for intracellular electrophysiological measurements at 200 ATA.

An apparatus has been constructed and tested at pressures to 200 ATA which meets the basic requirements for intracellular microelectrode work. Standard microelectrodes, unaffected by pressure in this range, were used with lobster axon and frog sartorius fibers and action potentials have been recorded at pressure up to 151 ATA. The chamber itself has a simple roll-in door and a modular design that recommends it as a highly convenient multipurpose vessel for work at moderately high pressures.