An anthropologist's viewpoint: observations and commentary regarding "Implementation of nursing vocabularies in computer-based systems".

Those who work in the area of vocabularies, like all researchers, bring some assumptions to that work. Such assumptions include both cultural notions and beliefs specific to particular social worlds within the broader society. In this article, assumptions and beliefs expressed by participants during the conference on "Implementation of Nursing Vocabularies in Computer-based Systems" are summarized. Questions are raised concerning the relationship between cultural notions and beliefs and nursing vocabularies.

An intelligent interactive system for delivering individualized information to patients.

This paper is a report on the first phase of a long-term, interdisciplinary project whose goal is to increase the overall effectiveness of physicians' time, and thus the quality of health care, by improving the information exchange between physicians and patients in clinical settings. We are focusing on patients with long-term and chronic conditions, initially on migraine patients, who require periodic interaction with their physicians for effective management of their condition. We are using medical informatics to focus on the information needs of patients, as well as of physicians, and to address problems of information exchange. This requires understanding patients' concerns to design an appropriate system, and using state-of-the-art artificial intelligence techniques to build an interactive explanation system. In contrast to many other knowledge-based systems, our system's design is based on empirical data on actual information needs. We used ethnographic techniques to observe explanations actually given in clinic settings, and to conduct interviews with migraine sufferers and physicians. Our system has an extensive knowledge base that contains both general medical terminology and specific knowledge about migraine, such as common trigger factors and symptoms of migraine, the common therapies, and the most common effects and side effects of those therapies. The system consists of two main components: (a) an interactive history-taking module that collects information from patients prior to each visit, builds a patient model, and summarizes the patients' status for their physicians; and (b) an intelligent explanation module that produces an interactive information sheet containing explanations in everyday language that are tailored to individual patients, and responds intelligently to follow-up questions about topics covered in the information sheet.

Selecting the appropriate rodent diet for endocrine disruptor research and testing studies.

Selecting the optimum diet for endocrine disruptor (ED) research and testing studies in rodents is critical because the diet may determine the sensitivity to detect or properly evaluate an ED compound. Dietary estrogens can profoundly influence many molecular and cellular event actions on estrogen receptors and estrogen-sensitive genes. The source, concentration, relative potency, and significance of dietary estrogens in rodent diets are reviewed, including dietary factors that focus specifically on total metabolizable energy and phytoestrogen content, which potentially affect ED studies in rodents. Research efforts to determine dietary factors in commercially available rodent diets that affect uterotrophic assays and the time of vaginal opening in immature CD-1 mice are summarized. A checklist is provided of important factors to consider when selecting diets for ED research and testing studies in rodents. Specific metabolizable energy levels are recommended for particular bioassays. Discussions include the between-batch variation in content of the phytoestrogens daidzein and genistein, the effects of total metabolizable energy and phytoestrogens on the timing (i.e., acceleration) of vaginal opening, and increased uterine weight in immature CD-1 mice. It is concluded that rodent diets differ significantly in estrogenic activity primarily due to the large variations in phytoestrogen content; therefore animal diets used in all ED studies should ideally be free of endocrine-modulating compounds.

New bottles, old wine: hidden cultural assumptions in a computerized explanation system for migraine sufferers.

Sophisticated computer programs known as "intelligent systems" have been developed for use in medical settings for over two decades. Such systems explicitly encode information about task domains, problem attributes, and problem-solving strategies. They also embody tacit assumptions held by those who build them, reflecting meanings taken for granted in particular cultural and disciplinary arenas. This article examines assumptions built into the design of a patient education system for migraine sufferers, drawing upon extended participant-observation of the development process. Its designers view the system as neutral, but observation reveals that it embodies a physician's point of view. While intended to support migraine patients by offering useful information not given them by physicians, the system in fact offers information characterized by the same assumptions and deletions as that provided by neurologists. Thus, although intended to empower migraine patients, this system may actually reinforce rather than reduce the power differential between doctor and patient.

Using ethnography to build a working system: rethinking basic design assumptions.

The problem of user acceptance of knowledge-based systems is a current concern in medical informatics. User acceptance should increase when system-builders understand both the needs of potential users and the context in which a system will be used. Ethnography is one source of such understanding. This paper describes the contribution of ethnography (and an anthropological perspective) during the first year of a three-year interdisciplinary project to build a patient education system on migraine. Systematic fieldwork is producing extensive data on the information needs of migraineurs. These data call into question some of the assumptions on which the project was based. While it is not easy to rethink our assumptions and their implications for design, using ethnography has enabled us to undertake this process relatively early in the project at a time when redesign costs are low. This should greatly improve our chances of building a system that meets the needs of real users, thus avoiding the troublesome problem of user acceptance.

Using ethnography to investigate life scientists' information needs.

Designing information resources that actually meet the information needs of individuals requires detailed knowledge of these needs. This poses a challenge for developers. Because the meaning of particular terms can vary by field, professional knowledge differs to some extent in different disciplines, and the questions that people ask assume a certain amount of unarticulated background knowledge, understanding the information needs of life scientists is not a trivial undertaking. One source of help in meeting this challenge is ethnography, a set of research methods and an associated conceptual stance developed and used by anthropologists for investigating uncontrolled real-world settings. Drawing on the author's experience in using ethnographic techniques to study clinicians' information needs, this paper describes why such research is necessary, why it requires particular research methods, what an ethnographic perspective has added to the study of information needs, and what this broader approach has revealed about the types of information sought by clinicians in the course of their daily practice.

Implementing computers in ambulatory care: implications of physician practice patterns for system design.

This paper presents pre-implementation data from the internal medicine division of a large physician group practice scheduled to implement an electronic medical record (EMR). Data were gathered through short-term participant observation and interviews. Findings indicate that (1) most physicians anticipate enough benefits to be willing to use the system; (2) computers must be accessible, easy to log into, and provide for physician movement and interrupted sessions; (3) many physicians are concerned about losing eye contact with patients; (4) it is unrealistic to expect even good typists to enter their own long notes; (5) staged implementation, with order entry introduced first, may help physicians adapt gradually; and (6) training should include protected time for instructional sessions for physicians, simulated patient encounters to help physicians adapt their practice patterns, and tutors available to answer questions in the clinical setting.

Broadening our approach to evaluating medical information systems.

Evaluation in medical informatics tends to follow the paradigm of controlled clinical trials. This model carries with it a number of assumptions whose implications for medical informatics deserve examination. In this paper, we describe the conventional wisdom on evaluation, pointing out some of its underlying assumptions and suggesting that these assumptions are problematic when applied to some aspects of evaluation. In particular, we believe that these assumptions contribute to the problem of user acceptance. We then suggest a broader approach to evaluation, offering some conceptual and methodological distinctions that we believe will be of use to the medical informatics community in rethinking this issue.

The effect of recombinant TGFalpha, human milk, and human milk macrophage media on gut epithelial proliferation is decreased in the presence of a neutralizing TGFalpha antibody.

OBJECTIVE: An in vitro model was devised to compare the relative effects of recombinant transforming growth factor-alpha (TGFalpha), aqueous human milk, and human milk macrophage (HMM) medium on human fetal small intestinal cell (FHs-74) proliferation. METHODS: Recombinant TGFalpha at increasing concentrations (range 0.01-1,000 ng/ml media), the aqueous fraction of human milk (AHM), or HMM medium was added to FHs-74 cells in the presence or absence of a neutralizing TGFalpha antibody (1 microgram/ml medium). At 24 h, cell proliferation was measured and expressed as percent control. The experimental variables were (1) activators of cell growth (TGFalpha, AHM, and HMM medium); (2) increasing concentrations of TGFalpha, and (3) neutralizing antibody to TGFalpha. The dependent variable for all experiments was cell proliferation. RESULTS: Significant effects for growth stimulators and TGFalpha concentration as measured by cell proliferation were found. Specifically, there was a dose-dependent effect of TGFalpha on cell proliferation to the 5-ng/ml concentration, with a plateau reached in cell proliferation at higher concentrations. The stimulatory effect of TGFalpha was decreased in the presence of TGFalpha antibody (mean +/- SD 22 +/- 7. 1% decline, p < 0.001). In the presence of TGFalpha antibody, there was a 25 +/- 3.1% decline in HM-stimulated growth (p < 0.004), and a 27.6 +/- 3.2% decline in HMM medium-stimulated growth (p < 0.001). CONCLUSIONS: Neutralization of recombinant TGFalpha and that present in human milk and HMM medium by TGFalpha antibody led to a consistent decrease in in vitro human fetal small intestine epithelial proliferation without affecting cell viability. These results support the hypothesis that TGFalpha, whether derived from human recombinant sources, human milk or HMM medium has a measurable, trophic effect on in vitro human gut epithelial cells.

Variation in the biochemical forms of transforming growth factor-alpha present in human milk and secreted by human milk macrophages.

OBJECTIVE: Transforming growth factor-alpha (TGF-alpha), present in human milk, is thought to play a significant role in postnatal gut development. Macrophages, which abound in human milk, are known to secrete various isoforms of TGF-alpha in other areas of the body. It was hypothesized that human milk macrophages (HMM) secrete TGF-alpha, and HMM are a source of TGF-alpha isoforms present in human milk. We sought to measure in vitro HMM TGF-alpha secretion, and to compare the TGF-alpha isoform(s) present in human milk with those secreted by HMM. STUDY DESIGN: Colostrum and mature milk samples, obtained from mothers (n = 48) on postpartum days 3-30, were centrifuged. HMM were isolated, placed in culture for 24 h, and cell-free media collected. The biochemical forms of TGF-alpha in media in human milk supernatant samples were identified by Western blot analysis under reducing conditions. The concentration of the mature (6-kD) TGF-alpha isoform in those samples was quantified using a radioimmunoassay. RESULTS: Western blot analysis under reducing conditions identified a single 6-kD TGF-alpha isoform in all human milk supernatant samples tested, but variable (6- and 30- to 46-kD) TGF-alpha isoforms in HMM media. The mean (+/- SE) concentration of the 6-kD TGF-alpha isoform found in human milk supernatants was 706 +/- 88 pg/ml and 17.6 +/- 2.6 pg/ml in HMM media. CONCLUSION: These experiments show that HMM secrete TGF-alpha in biochemical forms both similar to and distinct from that found in human milk supernatant.

Effect of human milk fortifier on the immunodetection and molecular mass profile of transforming growth factor-alpha.

OBJECTIVE: To determine if the addition of human milk fortifier (HMF) affects the distribution, immunoreactivity, or molecular mass profile of transforming growth factor-alpha (TGF-alpha) within the compartments of human milk. METHODS: Fifteen milk samples were obtained. Each sample was divided into two aliquots; a powdered HMF was added to the first aliquot. TGF-alpha concentration was measured via radioimmunoassay in whole milk and its aqueous and fat fractions +/- HMF. TGF-alpha molecular mass profiles of the samples (v/v) were measured via Western blotting. RESULTS: TGF-alpha concentration (mean +/- SD) in fortified whole milk (15.7 +/- 7.1 pg/100 microl) vs. nonfortified whole milk (14.8 +/- 8.0 pg/100 microl) and in the aqueous fraction of fortified (14.0 +/- 2.7 pg/100 microl) vs. nonfortified (14.0 +/- 3.5 pg/100 microl) did not differ statistically. There was, however, a marked decrease in the concentration of TGF-alpha in the fat fraction of fortified (30.6 +/- 2.8 pg/100 microl) vs. nonfortified (98.0 +/- 6.9 pg/100 microl) milk samples. Western blot for TGF-alpha in whole milk and its separated fractions revealed characteristic bands at 6.5, 12-16, 22, 26-30 and 46 kD. HMF alone and HMF with sodium taurocholate had a prominent band at 18 kD and fainter bands at 6.5, 26-30, and 46 kD. While whole and aqueous milk samples with HMF also consistently showed the 18-kD band, in 8/15 fat fraction samples with HMF the 18-kD band was nondetectable and was only faintly detectable in the remaining 7/15 samples. CONCLUSIONS: It appears that HMF differentially alters the biochemical profile of human milk with regard to TGF-alpha concentration and molecular mass profile. What effect this alteration in human milk biochemistry has on neonatal gut function remains unknown.

Involving patients in health care: explanation in the clinical setting.

The long-term goal of our research is to improve the overall effectiveness of physicians' time, by improving the information exchange between physicians and chronic-care patients, initially migraine patients. The computer system we are constructing has a partial knowledge base about migraines, common therapies, and common side effects of those therapies. The system consists of two main programs: data collection and explanation. The design of our system is based on empirical data concerning patients' information needs.

Expanding the concept of medical information: an observational study of physicians' information needs.

Obtaining and managing clinically relevant information constitutes a major problem for physicians, for which the development of automated tools is often proposed as a solution. However, designing and implementing appropriate automated solutions presumes knowledge of physicians' information needs. We describe an empirical study of information needs in four clinical settings in internal medicine in a university teaching hospital. In contrast to the retrospective data often used in previous studies, this research used ethnographic techniques to facilitate direct observation of communication about information needs. On the basis of this experience, we address two main issues: how to identify and interpret expressions of information needs in medicine and how to broaden our conception of "information needs" to account for the empirical data.

Secretion of transforming growth factor-alpha (TGF alpha) by postnatal rabbit alveolar macrophages.

Transforming growth factor-alpha (TGF alpha) is a cytokine secreted by stimulated alveolar macrophages (AM) in vitro and after in vivo particulate or hyperoxia exposure and has been implicated in the processes of postnatal lung development. It is unknown if AM TGF alpha secretion changes during normal postnatal lung development. After sacrifice of New Zealand white rabbits on postnatal d 0-2, 5-7, 9-10, 14, 21, and 28 and > 4 mo (adult), AM were isolated by discontinuous density centrifugation and placed in culture in the presence or absence of concanavalin A (ConA) for 24 h. Media were collected, and the concentration and isoforms of TGF alpha in AM media samples were determined by an epidermal growth factor/TGF alpha radioreceptor assay and Western immunodetection, respectively. TGF alpha was present in media of AM from the 1.06 and 1.08 g/dL Percoll densities, but not in the 1.10 g/dL density. Statistically significant differences in TGF alpha secretion by unstimulated and ConA-stimulated AM at the various ages were not detected until d 14 (p < 0.02). Western blot analysis of unstimulated AM media samples from d 0-7 rabbits demonstrated the presence of TGF alpha isoforms at 46, 30, and 14.3 kD. At later postnatal ages (> or = d 9), a single 14.3-kD isoform was present. In contrast, analysis of ConA-stimulated AM media samples showed TGF alpha isoforms at 46, 30, and 14.3 kD for all ages; however, the 6-kD mature isoform was present only in juvenile (d 28) and adult media.(ABSTRACT TRUNCATED AT 250 WORDS)

Support for information management in critical care: a new approach to identify needs.

Managing information is necessary to support clinical decision making and action in critical care. By understanding the nature of information management and its relationship to sound clinical practice, we should come to use technology more wisely. We demonstrated that a new approach inspired by ethnographic research methods could identify useful and unexpected findings about clinical information management. In this approach, a clinician experienced in a specific domain (critical care), with advice from a medical anthropologist, made short-term observations of information management in that domain. We identified 8 areas in a critical care Unit in which information management was seriously in need of better support. We also found interesting differences in how these needs were viewed by nurses and physicians. Our interest in this approach was at two levels: 1. Identify and describe representative instances of sub-optimal information management in a critical care Unit. 2. Investigate the effectiveness of such short-term observations by clinicians. Our long-range goal is to explore the use of this approach and the information it reveals to optimize the process of developing and selecting new information support tools, preparing for their introduction, and optimizing clinical outcomes.

Physicians' information needs: analysis of questions posed during clinical teaching.

OBJECTIVE: To describe information requests expressed during clinical teaching. SETTING: Residents' work rounds, attending rounds, morning report, and interns' clinic in a university-based general medicine service. SUBJECTS: Attending physicians, medical house staff, and medical students in a general medicine training program. METHODS: An anthropologist observed communication among study subjects and recorded in field notes expressions of a need for information. We developed a coding scheme for describing information requests and applied the coding scheme to the data recorded. Based on assigned codes, we created a subset of strictly clinical requests. MEASUREMENTS: Five hundred nineteen information requests recorded during 17 hours of observed clinical activity were selected for detailed analysis. These requests related to the care of approximately 90 patients by 24 physicians and medical students. Sixty-five requests were excluded because they were not strictly clinical, leaving a subset of 454 clinical questions for analysis. MAIN RESULTS: On average, five clinical questions were raised for each patient discussed. Three hundred thirty-seven requests (74%) concerned patient care. Of these 337 questions, 175 (52%) requested a fact that could have been found in a medical record. Seventy-seven (23%) of these questions, motivated by the needs of patient care, were potentially answerable by a library, a textbook, a journal, or MEDLINE. Eighty-eight (26%) of the questions asked for patient care required synthesis of patient information and medical knowledge. CONCLUSIONS: Clinicians in the study settings requested information frequently. Many of these information needs required the synthesis of patient information and medical knowledge and thus were potentially difficult to satisfy. A typology is proposed that characterizes information needs as consciously recognized, unrecognized, and currently satisfied.

Evaluation of Telazol-xylazine as an anesthetic combination for use in Syrian hamsters.

The availability of safe parenteral anesthetics for use in Syrian hamsters is limited. We evaluated the effects of Telazol-xylazine (TZX) combinations with respect to anesthetic efficacy and potential for tissue damage. Two dose levels of the combination were administered by both the intraperitoneal (IP) and intramuscular (IM) routes. TZX by the IM route failed to consistently produce anesthesia and caused gross and histopathologic muscle lesions. IP administration of 20 mg/kg Telazol combined with 10 mg/kg xylazine was adequate for restraint purposes. IP administration of 30 mg/kg Telazol combined with 10 mg/kg xylazine produced a safe, reliable level of surgical anesthesia without evidence of gross or histopathologic lesions. There was no nephrotoxicity at either concentration of the anesthetic. A dose level of TZX that provides safe parenteral anesthesia in Syrian hamsters was determined.