Translation of Contextual Control Model to chronic disease management: A paradigm to guide design of cognitive support systems.

BACKGROUND: Electronic health records (EHRs) continue to be criticized for providing poor cognitive support. Defining cognitive support has lacked theoretical foundation. We developed a measurement model of cognitive support based on the Contextual Control Model (COCOM), which describes control characteristics of an "orderly" joint system and proposes 4 levels of control: scrambled, opportunistic, tactical, and strategic. METHODS: 35 clinicians (5 centers) were interviewed pre and post outpatient clinical visits and audiotaped during the visit. Behaviors pertaining to hypertension management were systematically mapped to the COCOM control characteristics of: (1) time horizon, (2) uncertainty assessment, (3) consideration of multiple goals, (4) causal model described, and (5) explicitness of plan. Each encounter was classified for overall mode of control. Visits with deviation versus no deviation from hypertension goals were compared. RESULTS: Reviewer agreement was high. Control characteristics differed significantly between deviation groups (Wilcox rank sum p<.01). K-means cluster analysis of control characteristics, stratified by deviation were distinct, with higher goal deviations associated with more control characteristics. CONCLUSION: The COCOM control characteristics appear to be areas of potential yield for improved user-experience design.

Duration of transcranial magnetic stimulation effects on the neuroendocrine stress response and coping behavior of adult male rats.

BACKGROUND: Transcranial magnetic stimulation (TMS) is a relatively novel, noninvasive method of altering cerebral electrophysiological activity that produces localized and reversible changes in brain tissue. TMS has been shown to have antidepressant properties in both human trials and animal models. Additionally, TMS may alter hypothalamic-pituitary-adrenal (HPA) function resulting in a normalized dexamethasone suppression test in some depressed subjects and an attenuated stress-induced increase in adrenocorticotropic hormone (ACTH) and a possibly lowered basal corticosterone (CORT) concentration in rats. This research was undertaken to investigate the duration of these behavioral and neuroendocrine effects of TMS in rats. METHODS: In this study, serum ACTH, CORT, testosterone, and luteinizing hormone (LH) concentrations following and immobility parameters during a forced-swim test in adult male rats were evaluated immediately and 1, 3, 5, 7, and 14 days subsequent to a 10-day course of once-daily TMS or sham application. RESULTS: TMS animals had significantly higher ACTH and CORT concentrations immediately following the 10-day course of TMS compared to sham controls. Higher CORT concentrations (numerically but not statistically) were displayed by TMS-treated animals 1 and 3 days after the 10-day application course, although there were no significant differences between TMS and sham groups for ACTH or CORT levels 1, 3, 5, 7, and 14 days following application of sham or TMS. No significant differences were found between groups for serum testosterone and LH levels at any given collection time point. Immobility time, a measure of coping ability that is predictive of human antidepressant response, was significantly decreased (i.e., time spent actively swimming was significantly increased) immediately after the 10-day course of TMS. Thereafter, a nonsignificant numerical trend at 1 and 3 days after TMS application for immobility times between the TMS and control groups was observed (TMS