A comparison of the efficacy and safety of ceftizoxime with doxycycline versus conventional CDC therapies in the treatment of upper genital tract infection with or without a mass.

It is well known that sexually transmitted infections of the upper genital tract are widespread. A variety of regimens are used to treat these conditions, many of which have not been subjected to randomized, prospective clinical trials (including the 1985 Centers for Disease Control [CDC] Guidelines for the treatment of upper genital tract infections [UGTI]). This investigation was undertaken to compare the 1985 CDC treatment guidelines with different doses of ceftizoxime, a third-generation cephalosporin with an intermediate half-life, plus doxycycline in patients with UGTI. The patients were divided into subgroups, depending on the presence or absence of a pelvic mass. Sixty-seven women participated in the study. They were older than 14 years of age and required hospitalization for the treatment of UGTI. These women had lower abdominal pain and tenderness, cervical motion or adnexal tenderness, and one of the following: temperature greater than 100.4 degrees F orally, leukocytosis greater than 10,500/mm3, or presence of a suspected inflammatory pelvic mass on pelvic examination or by ultrasound. Informed consent was obtained from all patients in a manner approved by the Institutional Review Board. Pelvic examinations and ultrasound evaluations of the pelvic soft tissues were performed on all patients at the time of admission. Those who were found not to have a pelvic mass or who had a pelvic mass less than 4 cm in transverse diameter were randomly allocated to receive either ceftizoxime 2 gm intravenously every 12 hours with doxycycline 100 mg intravenously twice daily (Rx 1, n = 13) or cefoxitin 2 gm intravenously every six hours with doxycycline 100 mg intravenously twice daily (Rx 2, n = 14). Those patients found to have a pelvic mass (greater than 4 cm in transverse diameter) were randomly allocated to receive either ceftizoxime 2 gm intravenously every eight hours with doxycycline 100 mg intravenously twice daily (Rx 3, n = 19) or clindamycin 900 mg intravenously every eight hours with a 2-mg/kg loading dose of gentamicin followed by 1.5 mg/kg intravenously every eight hours, with adjustments as necessary (Rx 4, n = 21). All UGTI patients without a mass treated with either Rx 1 or Rx 2 responded adequately. However, UGTI patients with a mass treated with Rx 4 were more likely than those treated with Rx 3 to require a change in antibiotics or need extirpative surgery in order to obtain a satisfactory clinical response (Fisher's exact test = 0.046, two-sided).(ABSTRACT TRUNCATED AT 400 WORDS)

Prying questions about privacy in a nosy world.

The subject of this article is privacy and its relationship to the activities of health care organizations. Privacy is a good quality that each individual may possess. The quality of an individual's privacy is a personal determination. Although everyday life requires that we attempt to understand and protect the privacy of others, our efforts may be unsatisfactory despite our best intentions. If an individual believes that his or her privacy has been invaded, then it has been; no determination or opinion of a third party can alter that fact.

Intelligent processing of loosely structured documents as a strategy for organizing electronic health care records.

Loosely structured documents can capture more relevant information about medical events than is possible using today's popular databases. In order to realize the full potential of this increased information content, techniques will be required that go beyond the static mapping of stored data into a single, rigid data model. Through intelligent processing, loosely structured documents can become a rich source of detailed data about actual events that can support the wide variety of applications needed to run a health-care organization, document medical care or conduct research. Abstraction and indirection are the means by which dynamic data models and intelligent processing are introduced into database systems. A system designed around loosely structured documents can evolve gracefully while preserving the integrity of the stored data. The ability to identify and locate the information contained within documents offers new opportunities to exchange data that can replace more rigid standards of data interchange.

Cefmetazole and cefonicid. Comparative efficacy and safety in preventing postoperative infections after vaginal and abdominal hysterectomy.

A single 1-g dose of cefmetazole was compared with a single 1-g dose of cefonicid for prophylaxis in vaginal and abdominal hysterectomy to determine their efficacy and safety. The antibiotics were administered intramuscularly 15-90 minutes before the incision was made. Cefmetazole and cefonicid had similar activity against most of the aerobic organisms recovered, but cefmetazole was significantly more active against anaerobic gram-negative microorganisms. The patterns of regrowth of vaginal flora were similar in the two treatment groups. Patient demographic characteristics and surgical procedures were similar in both groups. The difference in primary prophylactic failure (e.g., cuff cellulitis) with the two study drugs (1 of 53 [1.9%] with cefmetazole and 2 of 28 [7.1%] with cefonicid) did not reach statistical significance, and the results were similar for the two routes of hysterectomy. Cefmetazole, at a dose of 1 g intramuscularly preoperatively, is a safe and effective agent for prophylaxis during hysterectomy.

Experimental identification of technical and database factors that can affect the success of clinical computer systems.

The entry of clinical data into computer systems is an extremely demanding form of transaction processing. High speed is important, especially if the collection involves real-time data. Clinicians must feel that they intuitively understand a system and that it is responsive. Medical data must be easily accommodated without sacrificing accuracy or completeness. Most systems cannot do this. Clinical systems that involve on-line storage of data from patients should employ data-base technology. Systems that lack any of the following capabilities will not succeed: manual data entry, a data dictionary, a file system, utility functions, ad hoc query, and a statistical report generator. These general capabilities must satisfy a number of specific functional requirements if the entire system is to be a success. A group of such requirements have been experimentally validated. These will be discussed and a more comprehensive list presented.

The application of the extracellular base excess to children.

The Base Excess of the Extracellular Fluid (BE-ecf) is the most complete model of acid-base physiology. It has gained considerable acceptance for use in adults as an index of the metabolic component of an acute acid-base disturbance. Several other commonly used indices were compared to the BE-ecf. The values of the Base Excess of Blood, Plasma Bicarbonate, Standard Bicarbonate, and T40-Bicarbonate differed significantly from the BE-ecf in 11.4, 6.3, 12.5, and 1.1% of samples, respectively. These differences are considered to be errors since the nonlinear relationship of the variables makes it difficult to clinically accommodate them. The standard (adult) form of the BE-ecf calculation overestimated the base excess by 1 meq/liter in 44.8% and by 2 meq/liter or more in 6.1% of samples from neonates and infants when compared to a form of the calculation which was individually adjusted based on the weight and hemoglobin concentration of each subject. Since it is no more difficult to make these corrections than to ignore them, if the BE-ecf is to be used in neonates and infants the correction should be applied.

Computerizing medical records: software criteria for systems to document patient encounters.

It is difficult to design and build computer systems to document medical care, especially if the entries are to be made by health care professionals. Not all software approaches are equally well suited to the task. Twenty-one specific software characteristics were identified that promote efficient development and support clinical needs. Using a software tool that satisfied these characteristics, we developed a computerized medical chart system that physicians can use to write notes and document patient encounters. The success of this system was due to a good fit between the basic capabilities of the software approach and the requirements of the project. These criteria can serve as the starting point for evaluating or developing other software applications that depend on physician input of clinical information.

An information model for medical events.

Information gathered during the healthcare process is lost when forced into rigidly structured record-oriented databases. By contrast, content can be difficult to manipulate if stored as unstructured text. Spurred by the requirements of electronic publishing, military procurement and the Internet, new robust standards for structuring documents have been developed and deployed. These standards can provide a foundation for a document-based Electronic Medical Record System. In order to fully exploit this added flexibility, an information model is necessary to define both the direct and contextual content of documents. Once context, as well as fact, are recorded in formal structures, inferential techniques can either selectively extract knowledge and data from documents or aggregate data to create summaries so that all interested and authorized parties have a better chance of meeting their information needs from a single, permanent data source.

A document processing architecture for electronic medical records.

An Electronic Medical Record System (EMRS) requires a deep analysis of the clinical workplace and of the character and uses of the medical record itself. Charts are a diverse and useful collection of loosely structured specialized documents, each with an orderly outline, but widely divergent and unpredictable contents--the more critical the case, the more unpredictable the details. This can be achieved by adapting an underlying information architecture that is based on document processing (rather than data processing), using the logic and conventions of text tagging, as in Mosaic, the Standard Generalized Markup Language (SGML), and HyTime.

Implementing a low-cost computer-based patient record: a controlled vocabulary reduces data base design complexity.

In order to build a computer-based patient record (CPR) system suitable for use in solo and small group practice settings it is necessary to use development methods that minimize cost. Design complexity is a major source of high cost. Reducing complexity should result in lower development, deployment and maintenance costs as well as higher reliability. We have developed a simplified relational model and have used that model, in conjunction with a controlled vocabulary, to implement a CPR that can capture and store patient examinations and other forms of clinical notes as well as laboratory and other test results. The information can be viewed in a familiar document format and it can accessed for other types of processing using standard Structured Query Language (SQL) techniques. The database, as implemented, uses inexpensive components resulting in a system that is not prohibitively expensive for solo practitioners and small groups. In addition the architecture is scaleable and can accommodate very large numbers of patients and practitioners.

Paediatric anaesthetic management with the aid of a computer.

A computer program has been developed to assist in the preparation of proper drug and anaesthetic doses for children. An individualized reference sheet containing the doses of the more commonly used drugs for the induction and maintenance of anaesthesia, fluid requirements, blood volume information, ventilatory variables, estimated endotracheal tube sizes and emergency drug doses constitutes the output of this program. The importance of such a computer program in improving paediatric anaesthetic management is discussed.

Pelvic abscesses in postmenopausal women.

Seventeen postmenopausal women with pelvic abscesses were cared for at the Los Angeles County-University of Southern California Women's Hospital during the past eight years. Nine had experienced either postmenopausal bleeding or uterine instrumentation, or both, within the prior six months. Findings from physical examination and various laboratory and roentgenologic studies did not significantly help in improving the accuracy of preoperative diagnosis. In four, the abscess was associated with intra-abdominal pathologic conditions, and six had poorly controlled adult onset diabetes mellitus. Transfusion was required in eight patients. Two patients had a prolonged hospital stay because of pulmonary and septic complications. One patient had carcinoma of the ovary while another had carcinoma of the cervix uteri that was undiagnosed preoperatively. Our conclusion is that about one-half of postmenopausal patients with pelvic and tubo-ovarian abscesses have postmenopausal bleeding. The remainder may have associated intra-abdominal infective pathologic findings or a malignant condition of the genital tract. Expeditious surgical treatment should be undertaken.

Development and assessment of a computer-based preanesthetic patient evaluation system for obstetrical anesthesia.

Computerization of the medical record in various outpatient settings has been successful but for anesthesiologists, the preoperative visit differs significantly. This study implemented a computerized version of a structured preanesthetic evaluation questionnaire that we had previously developed and which provided a starting point for developing a suitable vocabulary and workflow. Using the computerized version, pre-anesthetic evaluations were performed on 26 obstetric patients over a 20-week period. The introduction of a computer into the physician-patient relationship did not disrupt the examination. It markedly reduced time-consuming tasks (such as dictation), captured far more detail than found in our previously dictated and handwritten notes and provided immediately available data for quality assurance activities.