Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game.

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

HOLON/CADSE: integrating open software standards and formal methods to generate guideline-based decision support agents.

This paper describes the efforts of a consortium that is trying to develop and validate formal methods and a meta-environment for authoring, checking, and maintaining a large repository of machine executable practice guidelines. The goal is to integrate and extend a number of open software standards so that guidelines in the meta-environment become a resource that any vendor can plug their applications into and run in their proprietary environment provided they conform to the interface standards.

The use of infrared ear thermometers in pediatric and family practice offices.

OBJECTIVE: To describe the use of infrared (IR) ear thermometers in pediatric and family practice offices. METHODS: The authors mailed a questionnaire to 350 randomly selected members of the American Academy of Pediatrics and to 355 randomly selected members of the American Academy of Family Physicians. RESULTS: Of respondents in clinical practice, 78% had used IR ear thermometers at least once in the past; 65% of pediatricians and 64% of family practice physicians were current users. Seventeen percent of pediatric offices and 18% of family practice offices that had used IR ear thermometers had discontinued use, most citing inaccuracy or lack of staff trust in the device. Pediatric offices were less likely than family practice offices to use the device in well neonates and sick neonates and more likely to use it in sick children. Advantages cited included rapid readings, ease of use, and accuracy. Seventy-five percent of current users reported at least one problem, including low readings and lack of staff trust. CONCLUSIONS: IR ear thermometers are widely used in pediatric and family practice offices. Some offices limit use of these devices to older children and adults, and most of the offices surveyed report using other devices as a check on the accuracy of IR thermometers. Statements by professional organizations that provide user guidelines and establish appropriate age cut-offs would be helpful.

Web-based health care agents; the case of reminders and todos, too (R2Do2).

This paper describes efforts to develop and field an agent-based, healthcare middleware framework that securely connects practice rule sets to patient records to anticipate health todo items and to remind and alert users about these items over the web. Reminders and todos, too (R2Do2) is an example of merging data- and document-centric architectures, and of integrating agents into patient-provider collaboration environments. A test of this capability verifies that R2Do2 is progressing toward its two goals: (1) an open standards framework for middleware in the healthcare field; and (2) an implementation of the 'principle of optimality' to derive the best possible health plans for each user. This paper concludes with lessons learned to date.

The role of Web agents in medical knowledge management.

The intelligent agent approach offers the promise of remaking a traditional enterprise into a learning organization, one that uses progressive information technology and information strategies to study its outcomes prospectively, to avoid repetition of past errors, and to improve its effectiveness continuously. This paper explores whether agent technology can fulfill this promise in health care, both in a general sense and in terms of knowledge management and performance support. A case study is presented to illustrate some lessons learned and the pitfalls that need to be avoided as the development of agents proceeds.

Nationwide telecare for diabetics: a pilot implementation of the HOLON architecture.

This paper presents results from a demonstration project of nationwide exchange of health data for the home care of diabetic patients. A consortium of industry, academic, and health care partners has developed reusable middleware components integrated using the HOLON architecture. Engineering approaches for multi-organization systems development, lessons learned in developing layered object-oriented systems, security and confidentiality considerations, and functionality for nationwide telemedicine applications are discussed.

HOLON: extending Web document libraries via objects in order to support the health information infrastructure. Health Object Library Online.

In HOLON, user clients, applications, data servers, and fine-grained elements are all objects in a document library. To that end, this paper reviews the past year of progress and lessons learned in HOLON for integrating the Web, HL7, CORBA, Arden, KQML, UMLS Thesaurus, and other standards to determine if object technology reduces common problems in document-centric libraries such as indexing, searching/retrieving, complex data type management, and maintenance, among others.

Rupture of silicone-gel breast implants: causes, sequelae, and diagnosis.

Silicone-gel-filled breast implants have been widely used for breast augmentation and reconstruction after mastectomy. The rate of implant rupture and its sequelae are not known. We review the frequency, causes, sequelae, and detection of implant rupture. Materials testing of removed implants provides evidence that as implants age in vivo, they weaken and may rupture. Sequelae of rupture include migration of gel accompanied by inflammation and silicone granuloma formation. The role of free silicone gel in relation to idiopathic or atypical connective tissue disease is not clear. Magnetic resonance imaging is substantially more sensitive in the detection of rupture than is mammography or ultrasonography.

Home oxygen therapy in Medicare beneficiaries, 1991 and 1992.

STUDY OBJECTIVE: Obtain descriptive data on the use of home oxygen by Medicare beneficiaries and study the impact of certain demographic factors and diagnoses on oxygen use. METHODS: A home oxygen user was defined as any Medicare beneficiary with at least one claim for home oxygen in the Health Care Financing Administration National Claims History 5% Physician Supplier Files for 1991 and 1992. Railroad board beneficiaries, health maintenance organization members, and those without continuous part B coverage were excluded. RESULTS: In 1991, there were 21,489 beneficiaries in the sample who received oxygen therapy. In 1992, there were 8,418 new users. Twenty-six percent of new users died in 1992. Factors significantly associated with death included age 76 years or older (relative risk [RR], 1.3), pneumonia (RR, 1.3), lung cancer (RR, 3.8), male gender (RR, 1.2), heart failure (RR, 1.3), and diagnoses suggestive of COPD (RR, 0.45). Seven percent of new users discontinued therapy within 1 month, 28% within 6 months. Liquid oxygen was used by 19% of current and 14% of new users. Factors significantly associated with liquid oxygen use included portable oxygen claims (odds ratio [OR], 2.4), nonmetropolitan residence (OR, 0.73), and white race (OR, 1.2). CONCLUSIONS: Descriptive information on patterns of home oxygen use, including associated medical conditions, types and duration of therapy, and survival is useful for regulatory purposes. This information supports concerns that current payment policy may discourage suppliers from providing liquid oxygen in underserved areas.

HOLON: a Web-based framework for fostering guideline applications.

HOLON is a research and development effort in extending middleware in the healthcare field to support application development, in general, and guideline applications, in particular. This framework makes use of open standards for architecture, software, guideline KBs, clinical repository models, information encodings, and intelligent system modules and agents. By pursuing the use of such standards in our middleware components, we hope eventually to maximize reusability of the HOLON framework by others who also adhere to these open standards. This research reflects lessons learned about the extensions needed in these standards if healthcare middleware frameworks are to transparently support application developers and their users over the web.

Use and effectiveness of condoms during anal intercourse. A review.

BACKGROUND AND OBJECTIVES: Anal intercourse has been associated with a high risk of human immunodeficiency virus transmission. Survey data suggest that unprotected anal intercourse is practiced by a substantial proportion of the sexually active population, regardless of sexual orientation. GOAL: To review the literature related to the use and effectiveness of condoms during anal intercourse, with emphasis on prevention of human immunodeficiency virus transmission. STUDY DESIGN: Literature review. RESULTS: Epidemiologic studies have shown that consistent, correct condom use reduces the overall risk of sexual transmission of human immunodeficiency virus. Evidence for the effectiveness of condoms used during anal intercourse is less definitive. Survey and clinical trials data indicate that condom breakage and slippage rates vary during anal intercourse and may be considerably higher than during vaginal intercourse. Although condoms designed for anal intercourse have been studied and marketed in Europe, data on their actual performance are scarce. In addition, no information exists on the effectiveness of polyurethane or other nonlatex condoms for use during anal intercourse. CONCLUSIONS: Development of newer and more effective condoms for use during anal intercourse requires consideration of the ethical issues involved in testing and marketing devices used during an activity that carries with it the potential for a substantial risk to health.

Reported complications of silicone gel breast implants: an epidemiologic review.

PURPOSE: To review the range of local and systemic complications attributed to silicone breast implants and to evaluate the epidemiologic literature on these complications. DATA SOURCES: Epidemiologic studies of the potential risks of silicone breast implants identified by MEDLINE search and literature review. STUDY SELECTION: Epidemiologic studies with cohort, case-control, and cross-sectional designs. When epidemiologic studies were unavailable (as for estimates of local complications), case series were reviewed. DATA EXTRACTION: Epidemiologic studies evaluated for methodologic quality, including such characteristics as study design, sample size and selection, determination of silicone exposure and outcome variables, and duration of follow-up. DATA SYNTHESIS: The epidemiologic literature on the potential complications of silicone breast implants has concentrated primarily on connective tissue disorders and cancer. Estimated of the true incidence of local complications, such as rupture, capsular contracture, and breast pain, are unavailable. Studies of scleroderma and other defined connective tissue diseases suggest that implant recipients have no substantially increased risk for these disorders; however, the epidemiologic literature is insufficient to rule out an association between breast implants and connective tissue disease-like syndromes. Overall, the rate of breast cancer does not seem to be increased in women with silicone breast implants. However, the risk to women as they reach the postmenopausal years in not yet known. CONCLUSIONS: Information is insufficient to adequately advise women who currently have or are seeking to obtain breast implants about the overall risk of these devices. No epidemiologic study has indicated that the rate of well-defined connective tissue disease or breast cancer has greatly increased in women with silicone breast implants, but no studies have ruled out a moderately increased risk for these diseases. No studies have adequately addressed the crucial issue of local complications such as rupture and capsular contracture, although evidence increasingly points to a higher risk for rupture as implants age.

Prevalence of latex-specific IgE antibodies in hospital personnel.

BACKGROUND: Rubber latex hypersensitivity is an important concern for health care workers. PURPOSE: The Center for Devices and Radiological Health, in collaboration with the Consumer Product Safety Commission, conducted a multicenter study of the prevalence of latex-specific IgE antibodies among United States hospital personnel. MATERIALS AND METHODS: Nine hospitals participated in the cross-sectional study. A total of 504 hospital personnel completed questionnaires that provided an array of demographic, occupational, and clinical information, including a history, if any, of allergies and the use of latex and nonlatex gloves. More than three-quarters (76.5%) of the participants were tested for total IgE and latex specific IgE. RESULTS: A total of 21 (5.5%, 95% CI = 3%-7%) of the tested participants were positive for the presence of latex specific IgE antibodies, defined as a latex IgE level of > or = 0.6 ng/mL. Latex specific IgE antibodies were more prevalent in participants who reported tachycardia, palpitations, flushing, or wheezing associated with latex gloves (Odds Ratio = 10.2, 95% CI = 3.7-28.6). CONCLUSION: The study's results suggest that the prevalence of latex-specific IgE antibodies among hospital personnel is appreciable and these personnel and their health care providers should be aware of this entity.

The epidemiology of pacemaker implantation in the United States.

Data on pacemaker implantation were obtained from the Medical Device Implant Supplement to the 1988 National Health Interview Survey, a nationally representative, population-based survey of 47,485 households (122,310 persons). The survey yielded an estimate of 456,482 noninstitutionalized adults with pacemakers (prevalence, 2.6 per 1,000). Prevalence rose significantly with age, from 0.4 per 1,000 among persons ages 18-64 to 26 per 1,000 among those ages 75 or older. Age-adjusted prevalence in males was 1.5 times that in females, and in whites 1.6 times that in nonwhites, although these differences were of borderline statistical significance. Prevalence did not vary significantly by region of residence, educational level, or income, but was significantly increased (more than threefold) in those reporting any activity limitation compared with those with no limitation. Fifteen percent of pacemakers in use were replacements; about one-fifth of these had been replaced more than twice. Sixty percent of previous pacemakers had been in place for at least 5 years. These data provide the first nationwide, population-based estimates of the epidemiology of pacemaker implantation, focusing particularly on the demographics of U.S. pacemaker recipients.

The epidemiology of prosthetic heart valves in the United States.

The Center for Devices and Radiological Health of the Food and Drug Administration, in collaboration with the National Center for Health Statistics, conducted the Medical Device Implant Supplement to the 1988 National Health Interview Survey, generating the 1st available population-based estimates of the use of prosthetic heart valves in the United States. The 1988 National Health Interview Survey was a massive, nationally representative cross-sectional survey that encompassed 47,485 households and 122,310 individuals. Data from the Medical Device Implant Supplement indicate that an estimated 253,283 persons with 279,175 heart valves were present in the civilian, non-institutionalized US population (population prevalence of 1.1/1,000, 95% CI 0.8-1.3). Prevalence of valve prostheses ranged from 0.2 per 1,000 in those age 44 and under to 5.3 per 1,000 in those 75 years of age and older. Age-adjusted prevalence of valve prostheses did not differ significantly according to sex, race, region of residence, education, or income of recipients. Two thirds of aortic valve recipients identified by the survey were male, compared with only one third of mitral valve recipients. Approximately two thirds of both aortic and mitral valve implants were reported as mechanical. Reported use of anticoagulative agents was significantly more common in recipients of mechanical than of bioprosthetic valves. The single most common reported reason for prosthetic valve implantation was rheumatic heart disease. These data provide useful epidemiologic and public health planning information on prosthetic heart valve use.