Morphing as a means of generating variation in visual medical teaching materials.

In computer-based medical education, there is frequently a need to present students with pictorial data representative of the natural variation associated with disease presentations as well as the progression of disease within an individual. Because of the difficulty in acquiring such data, image acquisition is often the most resource-intensive phase of multimedia courseware development. In light of the resource demands associated with image content, many courseware designers do not make opportune use of image data, but rely instead upon text descriptions to provide variation in content. The resulting lack of adequate pictorial content often lessens the overall impact of the courseware. To overcome constraints imposed by the difficulty in acquiring pictorial content of sufficient richness, a methodology of generating variation in visual teaching materials has been developed through the use of morphing. These techniques have general applicability in creating variation in pictorial teaching materials in a variety of image-intensive domains.

[RSI: object and pretext for constructing the work and health field]. / LER: objeto e pretexto para a construção do campo trabalho e saúde.

This article presents a proposal for a research and action agenda in Workers' Health, taking the case of repetitive strain injury (RSI). It assumes that RSIs are both an object and a pretext for the Workers' Health area. As an object, RSIs demand both an understanding and resolution of problems as they present, and as a pretext, RSIs underscore the limits and contradictions of the paradigms adopted in Workers' Health. The article draws on data and questions raised in several studies.

[Use of the CAGE questionnaire for detecting alcohol use disorders in the emergency room]. / Emprego do questionário CAGE para detecção de transtornos de uso de álcool em pronto-socorro.

BACKGROUND: Alcoholism is seldom detected among emergency room outpatients, which is attributed to the non-adoption of diagnostic routines, to the difficulty of doing a special anamnesis for diagnosing alcoholism, and to the lack of sensitivity and specificity of the laboratory tests. This study has the purpose to determine whether the CAGE assay (composed by 4 questions of easy memorization) is able to supply this difficulty in detecting alcoholism. MATERIAL AND METHODS: We did a transversal study with consecutive sampling among outpatients of the Internal Medicine Department at Cajuru University Hospital emergency room. They were submitted to a standardized interview constituted by the CAGE and the CIDI assays (Composite International Diagnostic Interview, "demographics" and "disorders resulting from the use of alcohol" sections). From the sample obtained (n=374), we correlated the prevalence of alcoholism according to both questionnaires, considering the CIDI (DSM-IV criteria) to be the gold standard. RESULTS: The prevalence of alcohol dependence according to the DSM-IV criteria was 15.77%. We verified that the CAGE has 84.74% of sensitivity and 73.33% of specificity, with a cut point of 2 positive responses. CONCLUSIONS: We concluded that the CAGE is an instrument of easy application and good sensitivity and specificity when used at the emergency room, being able to supply the difficulties of alcoholism detection. We suggest that the CAGE be adapted as a routine at emergency rooms, increasing the alcoholism detection rate.

Transfer to a nitrocellulose membrane allows of the bone forming activity of bone morphogenetic protein.

When we purify bone morphogenetic protein (BMP), its activity diminishes, and the quantity we are able to extract decreases. It is difficult to evaluate the effects of each of the processes involved in BMP purification because it is unstable. In order to resolve the problem, a modified bioassay method using only slight quantities of BMP which do not decrease its bone-forming activity, is needed. We transferred BMP separated by sodium dodecylsulfate-polyacrylamide gel electrophoresis (SDS-PAGE) onto nitrocellulose membranes (NC) and cut out the bands. Then we used each band as implanted material. The NC membrane firmly bound the BMP activity fraction and held it in the implantation area of the mouse thigh. No formation of bone-like tissue was detected histologically at 14 days after the implantation, but, by 21 days after implantation, cartilage like tissue had clearly formed and newly formed bone was seen by 28 days. By implanting BMP transferred to individual NC membranes, we could perform a bioassay easily with small amounts of BMP without any reduction in activity.

Reducing risk with clinical decision support: a study of closed malpractice claims.

OBJECTIVE: Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). MATERIALS AND METHODS: Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type. RESULTS: Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for $40.3 million (58.9%) of indemnity. DISCUSSION: CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments. CONCLUSION: More than half of malpractice events and over $40 million of indemnity were potentially preventable with CDS.

Histone chaperones: 30 years from isolation to elucidation of the mechanisms of nucleosome assembly and disassembly.

Some three decades have passed since the discovery of nucleosomes in 1974 and the first isolation of a histone chaperone in 1978. While various types of histone chaperones have been isolated and functionally analyzed, the elementary processes of nucleosome assembly and disassembly have been less well characterized. Recently, the tertiary structure of a hetero-trimeric complex composed of the histone chaperone CIA/ASF1 and the histone H3-H4 dimer was determined, and this complex was proposed to be an intermediate in nucleosome assembly and disassembly reactions. In addition, CIA alone was biochemically shown to dissociate the histone (H3-H4)2 tetramer into two histone H3-H4 dimers. This activity suggested that CIA regulates the semi-conservative replication of nucleosomes. Here, we provide an overview of prominent histone chaperones with the goal of elucidating the mechanisms that preserve and modify epigenetic information. We also discuss the reactions involved in nucleosome assembly and disassembly.

[The common-sense knowledge and its implication for the occupational health surveillance] / As implicações do conhecimento prático para a vigilância em saúde do trabalhador.

This article deals with Occupational Health Surveillance as a health action induced by the workers' knowledge. In order to develop this conception, it adopts the notion of Health Surveillance, especially the concept of problem, and the notion of common-sense knowledge under the perspective used by social psychology. Supported by these considerations, we assume that the formulation of a health problem is a social representation. These considerations are used to examine the practice of "workers' investigations" as conceived by the Italian experience, pointing to its implications for the formulation of problems and identification of strategies in order to act on its determinants.

The findings--diagnosis continuum: implications for image descriptions and clinical databases.

As part of the Unified Medical Language System (UMLS) project, we have been exploring the use of semantic net representation to build a medical ontology that can adapt to the needs and perspective of differing kinds of users with varying purposes. A principal objective is to facilitate indexing and retrieval of objects in a variety of target databases, using their own source vocabularies, while maintaining the representation of concepts to which these source vocabularies refer in a single consistent form, so that retrievals that span resource types can be accommodated. In addition, a particular area of deficiency of the existing UMLS Metathesaurus is that of clinical findings, a part of the problem being the multiple alternative views and granularity levels at which clinical findings are described in different target databases. The problem is particularly obvious when one examines the way in which image findings are described, which may be at a purely perceptual level, or at varying levels of aggregation into higher level observations or interpretations. We have developed a recursive model for representing observations and interpretations in a semantic net along a continuum of degree of aggregation, that appears to lend itself well to adaptation to varying perspectives.

Enhancing the Metathesaurus with clinically relevant concepts: anatomic representations.

To create a comprehensive taxonomy for medical concepts it is necessary to identify gaps and reconcile differences that exist between clinical, bibliographic, and other source vocabularies. As part of the Unified Medical Language System project, we have proposed enhancements to the Metathesaurus by the inclusion of terms from two source vocabularies with different unique perspectives or views. This process has disclosed a number of issues that arise as complexity increases. These issues must be resolved if the resultant Metathesaurus is to support the variety of uses for which it is intended.

Representation of clinical practice guidelines through an interactive World-Wide-Web interface.

The widespread utility of clinical practice guidelines is greatly dependent on the ease with which they can be accessed, used, and applied. Because it supports hyperlinking and is widely accessible, the World-Wide Web is a medium that is well suited for browsing through guidelines. We have developed a process for implementing algorithmic guidelines into a graphical format that allows the user to browse these guidelines in an interactive fashion. The guidelines we used were already in or could be transformed to an algorithmic format that lends itself well to analysis with decision table techniques, which in turn permits a fairly straightforward conversion into a graphical representation. The results of this process allow a user to browse a particular guideline algorithm and to visualize the traversed parts of the algorithm by flowcharts. Our first experiences with this method of representing a few sample clinical practice guidelines have been encouraging, and we hope to extend this method to other guidelines.

The representation of time in clinical patient simulations.

Simulated clinical scenarios are generally compressed in time to enhance educational effectiveness and to minimize testing time. Designers should consider how to best control potential sources of distortion in the perception of time and how to best communicate the passage of time to the user.

A potent naturally occurring low-molecular weight blastogenic inhibitory factor from edible black tree fungus.

Crude dialyzable extracts of Auricularia polytricha (black tree fungus) when added to lymphoprep-isolated blood mononuclear cells (PBL) stimulated with mitogens (PHA and PWM) showed significant inhibition of 3H-thymidine (3H-TdR) incorporation in vitro. Similar extracts of Agaricus biporus and Cortinellus shiitake demonstrated essentially no suppression of 3H-TdR uptake by PBL cells stimulated with PHA or PWM. A 50 micrograms/well (200 microliter) concentration of A. polytricha reduced 3H-TdR uptake of PHA stimulated PBL cells from different donors by 65.4 to 99.8% and similarly reduced 3H-TdR uptake of PWM stimulated PBL cells by 89.6 to 99.9%. Viability examination of PBL cells in RPMI medium with A. polytricha extract alone, mitogens alone, and mixtures of mitogens and extract for 72 hr at 37 degrees C showed per cent survivals as follows: medium alone, 93%; PWM, 91%; PHA, 77%; BTF extract (200 micrograms/ml), 57%; PWM + BTF extract, 47%, and PHA + BTF extract, 39%. Data presented show that Auricularia polytricha contained a low dalton potent blastogenic inhibitory factor(s).

Effect of a pharmacy-based cost-containment program on cimetidine costs and use.

A program developed by the University of California at San Diego Medical Center to curb over-prescribing of cimetidine is described. Guidelines for cimetidine use were approved in September 1985. Pharmacists undertook physician education and enforced the guidelines by monitoring patients through a specially designed documentation form. When use of cimetidine was not in compliance with the guidelines, the pharmacists contacted the physicians to recommend changes. Use of cimetidine hydrochloride injection declined 49% between September 30 and December 6, 1985. Extrapolated to an entire year, this reduction would result in cost savings of +12,000 to +16,000. However, after pharmacists stopped enforcing the guidelines in December 1985, use of cimetidine hydrochloride injection gradually increased to near control levels. In February 1986, the review of patients receiving cimetidine was reinstituted, resulting in another decline in use. Periodic review and reinforcement by pharmacists appear necessary to ensure that cimetidine continues to be prescribed appropriately.

Facilitating physician referrals on the World Wide Web: representation and appropriate utilization of clinical expertise.

In highly integrated and increasingly complex health care systems, the identification and proper utilization of clinical staff expertise are key factors for efficiently delivering high quality patient care. To achieve these capabilities on an enterprise-wide scale, we have embarked on a multi-phased project to develop World Wide Web (WWW)-based physician referral capabilities for two large teaching hospitals. Currently, users may search for information concerning the education, training, board certifications, and self-designated clinical interests of staff members. Address, phone number, email address, and a photo are also presented. Our experience indicates that institutional changes are required to successfully deploy and maintain online physician referral services and that accurate and equitable representation of clinical expertise and the incorporation of referral guidelines require an incremental introduction of a carefully planned program that addresses the needs of clinicians, administrators, and health care policy-makers.

The PartnerWeb Project: a component-based approach to enterprise-wide information integration and dissemination.

A component-based health information resource, delivered on an intranet and the Internet, utilizing World Wide Web (WWW) technology, has been built to meet the needs of a large integrated delivery network (IDN). Called PartnerWeb, this resource is intended to provide a variety of health care and reference information to both practitioners and consumers/patients. The initial target audience has been providers. Content management for the numerous departments, divisions, and other organizational entities within the IDN is accomplished by a distributed authoring and editing environment. Structured entry using a set of form tools into databases facilitates consistency of information presentation, while empowering designated authors and editors in the various entities to be responsible for their own materials, but not requiring them to be technically skilled. Each form tool manages an encapsulated component. The output of each component can be a dynamically generated display on WWW platforms, or an appropriate interface to other presentation environments. The PartnerWeb project lays the foundation for both an internal and external communication infrastructure for the enterprise that can facilitate information dissemination.

Emprego do questionário CAGE para detecçäo de transtornos de uso de álcool em pronto-socorro / Use of the CAGE questionnaire for detecting alcohol use disorders at the emergency room

OBJETIVO: Determinar se o questionário CAGE (composto por quatro perguntas de fácil memorizaçäo) é capaz de suprir a dificuldade de detecçäo do alcoolismo. MATERIAL E METODO: Realizamos um estudo transversal com amostragem consecutiva em pacientes da Clínica Médica do pronto-socorro do Hospital Universitário Cajuru, os quais foram submetidos a uma entrevista padronizada constituída pelo questionário CAGE e pelo CIDI (Composite International Diagnostic Interview, seções "demografia" e "desordens resultantes do uso de ßlcool"). Da amostra obtida (n=374), correlacionamos a prevalência de alcoolismo segundo ambos os questionários, considerando o CIDI (critérios do DSM-IV) como sendo o padräo-ouro. RESULTADOS: A prevalência de dependência de álcool segundo os critérios do DSM-IV foi de 15,77 por cento. Nós verificamos que o CAGE possui sensibilidade igual a 84,74 por cento e especificidade igual a 73,33 por cento para um ponto de corte igual a duas respostas afirmativas. Conclusöes: Concluímos que o questionário CAGE é um instrumento de fácil aplicaçäo e boa sensibilidade e especificidade quando usado no ambiente de pronto-socorro, podendo suprir as dificuldades de detecçäo do alcoolismo. Sugerimos que o questionário CAGE seja adotado como rotina no pronto-socorro, permitindo que o Ýndice de detecçäo de alcoolismo aumente