REDCap on FHIR: Clinical Data Interoperability Services.

BACKGROUND: Despite widespread use of electronic data capture (EDC) systems for research and electronic health records (EHR), most transfer of data between EHR and EDC systems is manual and error prone. Increased adoption of Health Level Seven Fast Healthcare Interoperability Resource (FHIR) application programming interfaces (APIs) in recent years by EHR systems has increased the availability of patient data for external applications such as REDCap. OBJECTIVE: Describe the development of the REDCap Clinical Data Interoperability Services (CDIS) module that provides seamless data exchange between the REDCap research EDC and any EHR system with a FHIR API. CDIS enables end users to independently set up their data collection projects, map EHR data to fields, and adjudicate data transfer without project-by-project involvement from Health Information Technology staff. METHODS: We identified two use cases for EHR data transfer into REDCap. Clinical Data Pull (CDP) automatically pulls EHR data into user-defined REDCap fields and replaces the workflow of having to transcribe or copy and paste data from the EHR. Clinical Data Mart (CDM) collects all specified data for a patient over a given time period and replaces the process of importing EHR data for registries from research databases. With an iterative process, we designed our access control, authentication, variable selection, and mapping interfaces in such a way that end users could easily set up and use CDIS. RESULTS: Since its release, the REDCap CDIS has been used to pull over 19.5 million data points for 82 projects at Vanderbilt University Medical Center. Software and documentation are available through the REDCap Consortium. CONCLUSIONS: The new REDCap Clinical Data and Interoperability Services (CDIS) module leverages the FHIR standard to enable real-time and direct data extraction from the EHR. Researchers can self-service the mapping and adjudication of EHR data into REDCap. The uptake of CDIS at VUMC and other REDCap consortium sites is improving the accuracy and efficiency of EHR data collection by reducing the need for manual transcription and flat file uploads.

Floral Colonization Dynamics and Specificity of Aureobasidium pullulans Strains Used to Suppress Fire Blight of Pome Fruit.

Aureobasidium pullulans is used as a biocontrol agent for fire blight protection in organic apple and pear production. We assessed colonization of pome flowers by A. pullulans in orchards located near Corvallis, OR and Wenatchee, WA. Blossom Protect, a mix of A. pullulans strains CF10 and CF40, and its citrate-based companion, Buffer Protect, were sprayed at 70% bloom. Later in bloom, the population size of putative A. pullulans on flowers was estimated by dilution plating; plate scrapings of putative A. pullulans were then sampled and subjected to a PCR analysis. Sequenced PCR amplicons of the internal transcribed spacer region and the elongase gene confirmed the presence of A. pullulans, whereas a multiplex PCR with primers specific to CF10 and CF40 was used to determine the presence of the introduced strains. At Corvallis, a wet spring environment, A. pullulans, was recovered from most (>90%) Bartlett pear and Golden Delicious apple flowers sampled from experimental trees, regardless of whether the trees were treated with Blossom Protect. Nevertheless, population size estimates of A. pullulans on the flowers were correlated with the number of times Blossom Protect was sprayed on the trees. At Wenatchee, an arid spring environment, A. pullulans was detected on most flowers from trees treated with Blossom Protect, but only on a minority of flowers from nontreated controls. In both locations, the combined incidence of strains CF10 and CF40 on flowers averaged 89% on Blossom Protect-treated trees, but only 27% on adjacent, nontreated trees. During subsequent trials, the efficacy of Blossom Protect for fire blight control was compared with alternative yeast isolates, with each applied with Buffer Protect; local isolates of A. pullulans and Cryptococcus neoformans and a postharvest biocontrol strain of Cystofilobasidium infirmominiatum were used All yeast strains suppressed fire blight to a degree; however, in each of four trials, the level of suppression was highest with Blossom Protect, and it was significantly superior (P ≤ 0.05) to other yeast isolates in two of the trials. Because A. pullulans strains CF10 and CF40 were detected primarily on flowers on trees treated with Blossom Protect, and because they were detected much less frequently on nearby nontreated tress, we recommend treating every tree row with Blossom Protect at least once for organic fire blight suppression.

Conceptual and technical insights into the basis of neuromuscular monitoring.

Unrecognised postoperative residual neuromuscular block remains a frequent occurrence in recovery rooms. Evidence indicates that current practice continues to perpetuate the status quo, in which 10-40% of patients experience postoperative residual weakness. A departure from the current practice requires small efforts on the clinicians' part. This review addresses several selected core questions regarding neuromuscular blockade monitoring and provides a framework to rationally discuss and develop basic guidelines for the use of neuromuscular blocking agents in patient care.

Opportunities and challenges for biomarker discovery using electronic health record data.

Electronic health records (EHRs) have become increasingly relied upon as a source for biomedical research. One important research application of EHRs is the identification of biomarkers associated with specific patient states, especially within complex conditions. However, using EHRs for biomarker identification can be challenging because the EHR was not designed with research as the primary focus. Despite this challenge, the EHR offers huge potential for biomarker discovery research to transform our understanding of disease etiology and treatment and generate biological insights informing precision medicine initiatives. This review paper provides an in-depth analysis of how EHR data is currently used for phenotyping and identifying molecular biomarkers, current challenges and limitations, and strategies we can take to mitigate challenges going forward.

Mechanistically compatible mixtures of bacterial antagonists improve biological control of fire blight of pear.

Mixtures of biological control agents can be superior to individual agents in suppressing plant disease, providing enhanced efficacy and reliability from field to field relative to single biocontrol strains. Nonetheless, the efficacy of combinations of Pseudomonas fluorescens A506, a commercial biological control agent for fire blight of pear, and Pantoea vagans strain C9-1 or Pantoea agglomerans strain Eh252 rarely exceeds that of individual strains. A506 suppresses growth of the pathogen on floral colonization and infection sites through preemptive exclusion. C9-1 and Eh252 produce peptide antibiotics that contribute to disease control. In culture, A506 produces an extracellular protease that degrades the peptide antibiotics of C9-1 and Eh252. We hypothesized that strain A506 diminishes the biological control activity of C9-1 and Eh252, thereby reducing the efficacy of biocontrol mixtures. This hypothesis was tested in five replicated field trials comparing biological control of fire blight using strain A506 and A506 aprX::Tn5, an extracellular protease-deficient mutant, as individuals and combined with C9-1 or Eh252. On average, mixtures containing A506 aprX::Tn5 were superior to those containing the wild-type strain, confirming that the extracellular protease of A506 diminished the biological control activity of C9-1 and Eh252 in situ. Mixtures of A506 aprX::Tn5 and C9-1 or Eh252 were superior to oxytetracycline or single biocontrol strains in suppressing fire blight of pear. These experiments demonstrate that certain biological control agents are mechanistically incompatible, in that one strain interferes with the mechanism by which a second strain suppresses plant disease. Mixtures composed of mechanistically compatible strains of biological control agents can suppress disease more effectively than individual biological control agents.

Control of fire blight by Pseudomonas fluorescens A506 and Pantoea vagans C9-1 applied as single strains and mixed inocula.

The biological control agents Pseudomonas fluorescens A506 and Pantoea vagans C9-1 were evaluated individually and in combination for the suppression of fire blight of pear or apple in 10 field trials inoculated with the pathogen Erwinia amylovora. The formulation of pathogen inoculum applied to blossoms influenced establishment of the pathogen and the efficacy of biological control. Pantoea vagans C9-1 suppressed fire blight in all five trials in which the pathogen was applied as lyophilized cells but in none of the trials in which the pathogen was applied as freshly harvested cells. In contrast, Pseudomonas fluorescens A506 reduced disease significantly in only one trial. A mixture of the two strains also suppressed fire blight, but the magnitude of disease suppression over all field trials (averaging 32%) was less than that attained by C9-1 alone (42%). The two biological control agents did not antagonize one another on blossom surfaces, and application of the mixture of A506 and C9-1 to blossoms resulted in a greater proportion of flowers having detectable populations of at least one bacterial antagonist than the application of individual strains. Therefore, the mixture of A506 and C9-1 provided less disease control than expected based upon the epiphytic population sizes of the antagonists on blossom surfaces. We speculate that the biocontrol mixture was less effective than anticipated due to incompatibility between the mechanisms by which A506 and C9-1 suppress disease.

Factors Influencing Epidemiology and Management of Blackberry Rust in Cultivated Rubus laciniatus.

The blackberry rust pathogen Phragmidium violaceum was first observed in Oregon in spring 2005 on both commercially cultivated Rubus laciniatus (Evergreen blackberry) and naturalized R. armeniacus (Himalayan blackberry). Several commercial plantings suffered severe economic losses. In 2006 to 2008, all five spore stages of this autoecious, macrocyclic rust pathogen were observed annually, and asexual perennation of the pathogen on old leaves or in leaf buds was not evident in the disease cycle. In field experiments, teliospore germination and infection by basidiospores occurred mostly during April. On potted "trap" plants exposed for periods of 1 week under dense collections of dead leaves bearing teliospores, basidiospore infection was associated with wetness durations of >16 h with mean temperatures >8°C. Trap plants placed under the bundles of collected leaves frequently developed spermagonia, whereas only 1 of 630 trap plants placed in a production field of R. laciniatus became diseased, an indication that the effective dispersal distance of basidiospores may be limited. In growth chambers programmed for constant temperatures of 5, 10, 15, 20, 25, and 30°C, a minimum of six continuous hours of leaf wetness was required for infection by urediniospores, with >9 h required for moderate infection (>4 pustules/cm2) at 15 and 20°C. With diurnal temperature regimes averaging 5, 10, 15, 20, or 25°C, urediniospore germination and infection was highest in the range of 5 to 15°C; similarly, in the diurnal environment, >9 h of leaf wetness was required to attain moderate infection. In the field, lime sulfur applied as a delayed dormant treatment significantly suppressed teliospore germination and basidiospore infection. Over two seasons, one application of myclobutanil, a demethylation-inhibitor fungicide, applied in early May near the time of spermagonial appearance provided effective suppression of the summer epidemic.

Implications of pathogenesis by Erwinia amylovora on rosaceous stigmas to biological control of fire blight.

As a prerequisite to infection of flowers, Erwinia amylovora grows epiphytically on stigmas, which provide a conducive habitat for bacterial growth. Stigmas also support growth of several other bacterial genera, which allows for biological control of fire blight; although, in practice, it is very difficult to exclude E. amylovora completely from this habitat. We investigated the dynamics of growth suppression of E. amylovora by comparing the ability of virulent and avirulent strains of E. amylovora to compete with each other on stigmas of pear, apple, and blackberry, and to compete with a co-inoculated mixture of effective bacterial antagonists. When strains were inoculated individually, virulent E. amylovora strain Ea153N attained the highest population size on stigmas, with population sizes that were approximately double those of an avirulent hrpL mutant of Ea153 or the bacterial antagonists. In competition experiments, growth of the avirulent derivative was suppressed by the antagonist mixture to a greater extent than the virulent strain. Unexpectedly, the virulent strain enhanced the population size of the antagonist mixture. Similarly, a small dose of virulent Ea153N added to inoculum of an avirulent hrpL mutant of Ea153 significantly increased the population size of the avirulent strain. A pathogenesis-gene reporter strain, Ea153 dspE::gfp, was applied to flowers and a subset of the population expressed the green fluorescent protein while growing epiphytically on stigmas of apple. These results are consistent with the hypothesis that virulent E. amylovora modifies the epiphytic habitat presented by the stigma through a pathogenesis-related process, which increases host resources available to itself and, coincidentally, to nonpathogenic competitors. Over nine orchard trials, avirulent Ea153 hrpL significantly suppressed the incidence of fire blight four times compared with six for the antagonist mixture. The degree of biological control achievable with an avirulent strain of E. amylovora likely is limited by its inability to utilize the stigmatic habitat to the same degree as a virulent strain.

Rates of Epiphytic Growth of Erwinia amylovora on Flowers Common in the Landscape.

We evaluated epiphytic growth of the fire blight bacterium, Erwinia amylovora, on flowers of plant species common to landscapes where pears and apples are grown. The plants were from genera regarded as important nectar and pollen sources for pollinating insects: Acer, Amelanchier, Brassica, Cytisus, Populus, Prunus, Rubus, Salix, Taraxacum, Trifolium, and Symphoricarpos. Floral bouquets were inoculated with E. amylovora and incubated in growth chambers at 15°C for 96 h. Regardless of their susceptibility to fire blight, all species from the rose family except Prunus domestica (European plum) supported epiphytic populations of E. amylovora that exceeded 1 × 106 CFU/flower with relative growth rates for the populations that averaged 7% per hour. Nonrosaceous plants were generally poor supporters of epiphytic growth of the fire blight pathogen with relative growth rates averaging <4% per hour. In two seasons of field inoculations, the rosaceous non-disease-host plants, Prunus avium (sweet cherry) and Rubus armeniacus (Himalayan blackberry), yielded mean population sizes of E. amylovora that exceeded 1 × 106 CFU/flower; in contrast, at 8 days after inoculation, mean population sizes of the pathogen were in the range of 5 × 103 to 5 × 104 CFU/flower on Cytisus scoparius (Scotch broom) and <1 × 102 CFU on Acer macrophylum (big leaf maple). Because vectors of E. amylovora, principally bees, visit many kinds of flowers in landscape areas between pear and apple orchards, flowers of rosaceous, non-disease-host species could serve as potential sites of inoculum increase during their periods of bloom.

Management of fire blight: a case study in microbial ecology.

Suppression of the blossom-blight phase of fire blight is a key point in the management of this destructive and increasingly important disease of apple and pear. For blossom infection to occur, the causal bacterium, Erwinia amylovora, needs to increase its population size through an epiphytic phase that occurs on stigmatic surfaces. Knowledge of the ecology of the pathogen on stigmas has been key to the development of predictive models for infection and optimal timing of antibiotic sprays. Other bacterial epiphytes also colonize stigmas where they can interact with and suppress epiphytic growth of the pathogen. A commercially available bacterial antagonist of E. amylovora (BlightBan, Pseudomonas fluorescens A506) can be included in antibiotic spray programs. Integration of bacterial antagonists with chemical methods suppresses populations of the pathogen and concomitantly, fills the ecological niche provided by the stigma with a nonpathogenic, competing microorganism. Further integration of biologically based methods with conventional management of blossom blight may be achievable by increasing the diversity of applied antagonists, by refining predictive models to incorporate antagonist use, and by gaining an improved understanding of the interactions that occur among indigenous and applied bacterial epiphytes, antibiotics, and the physical environment.

Physician response to implementation of genotype-tailored antiplatelet therapy.

Physician responses to genomic information are vital to the success of precision medicine initiatives. We prospectively studied a pharmacogenomics implementation program for the propensity of clinicians to select antiplatelet therapy based on CYP2C19 loss-of-function variants in stented patients. Among 2,676 patients, 514 (19.2%) were found to have a CYP2C19 variant affecting clopidogrel metabolism. For the majority (93.6%) of the cohort, cardiologists received active and direct notification of CYP2C19 status. Over 12 months, 57.6% of poor metabolizers and 33.2% of intermediate metabolizers received alternatives to clopidogrel. CYP2C19 variant status was the most influential factor impacting the prescribing decision (hazard ratio [HR] in poor metabolizers 8.1, 95% confidence interval [CI] [5.4, 12.2] and HR 5.0, 95% CI [4.0, 6.3] in intermediate metabolizers), followed by patient age and type of stent implanted. We conclude that cardiologists tailored antiplatelet therapy for a minority of patients with a CYP2C19 variant and considered both genomic and nongenomic risks in their clinical decision-making.

Discharging patients with prescriptions instead of medications: sequelae in a teaching hospital.

OBJECTIVE: This study measures the incidence of discrepancies among written prescriptions, medication regimens transcribed onto patient discharge instruction sheets (DCIs), and labels on medications dispensed by community pharmacies after discharge of patients from an academic medical center. METHODS: During a 2-month study period, we collected copies of prescriptions and DCIs. We also called care givers after discharge and asked them to read the medication labels that were filled from discharge prescriptions. Care givers were also asked whether they received instruction from community pharmacies. RESULTS: Data were collected on 335 prescriptions for 192 patients. Differences among the prescriptions, DCIs, and medication labels were found for 40 (12%) of the medications prescribed at discharge, representing 19% of the patients studied. Nineteen prescriptions had prescriber errors in dosing frequencies or dosage formulations. Three prescriptions were filled with different medication concentrations or strengths than requested. Prescriptions were altered by the community pharmacists for unexplained reasons in 6 cases, whereas the DCIs and original prescriptions differed in 12 cases. Only 44% of families were counseled about proper medication administration by their pharmacists. CONCLUSIONS: A potential for medication errors exists when pediatric patients are discharged with unfilled prescriptions. The potential may be worsened when discharge instructions are created from a prescription rather than from the label of a dispensed medication. Educational and risk-management efforts should emphasize the importance of writing complete, legible prescriptions and consulting appropriate reference materials to ensure that dose formulations and guidelines are accurate. Whenever possible, prescriptions should be filled before patients are discharged, so that the dispensed medications can be reviewed, and health care providers can provide accurate discharge instructions.

The effect of hypothermia on potassium and glucose changes in isobaric hemorrhagic shock in the rat.

Hypothermia has been shown to decrease oxygen consumption requirements and improve survival during hemorrhagic shock. however, hypothermia applied therapeutically does not prevent the development of a lactic acidosis during hemorrhage. We re-examined the development of a hemorrhage-induced lactic acidosis and other metabolic parameters (glucose, plasma electrolytes, and arterial blood gases) at various temperatures (29-37 degrees C) to better define the protective action of hypothermia in hemorrhagic shock. Five groups of male, Sprague-Dawley rats were bled to a mean arterial blood pressure (MABP) of 40 mmHg over a 15 min period and held there by further blood removal until death. The final level and rate of development of the lactic acidemia was the same in all groups. However, the rate of decline in plasma glucose and rate of rise in plasma potassium were temperature dependent. These results suggest that temperature-dependent changes in serum glucose and potassium may contribute to the protective effect of hypothermia during hemorrhagic shock.

Plasma and tissue histamine changes during hemorrhagic shock in the rat.

We investigated the phase-associated changes in plasma histamine levels in an isobaric model of hemorrhagic shock, in an attempt to determine whether histamine might be an etiologic factor in the onset of decompensation. Sprague-Dawley rats were bled according to an isobaric bleeding protocol which maintained the mean arterial blood pressure at 40 mmHg until death. The status of vascular compensation for the blood loss was tracked by measurement of the shed blood volume (SBV) required to maintain the target pressure. Blood samples for analysis were taken at the control period and at 25% intervals of the peak shed blood volume (PSBV) during the compensatory and decompensatory phases. Plasma and tissue histamine levels were measured using a radioimmunoassay method. In untreated animals, plasma histamine levels at control, 75 and 100% of the PSBV, and after return of 25 and 75% of the PSBV were 45 +/- 10, 48 +/- 9,134 +/- 48,693 +/- 351, and 994 +/- 371 nM, respectively. These results show that rises in plasma histamine occurred coincidentally with the onset of decompensation (p < .05), however, the subsequent rate of decompensation did not correlate with plasma histamine changes during decompensation. Organ histamine levels measured after hemorrhage were lower in the duodenum and colon than in unbled control animals, suggesting that parts of the intestinal tract may contribute to the elevated plasma histamine levels seen in severe hypotension (p < .05).

The role of histamine in mediating the decompensatory phase of hemorrhagic shock in the rat.

Our laboratory has previously reported that plasma histamine levels rise significantly and coincidentally with the onset of the decompensatory phase of isobaric hemorrhagic shock in rats. The histamine levels seen in shock were comparable to those that induce profound vasodilatation in many vascular beds under normovolemic conditions. We, therefore, sought to determine whether the elevation in plasma histamine contributes to the cardiovascular collapse seen in the decompensatory phase of hemorrhagic shock. Sprague-Dawley rats were bled according to an isobaric bleeding protocol which maintained the mean arterial blood pressure (MAP) at 40 mmHg until death. Selected H1 (diphenhydramine) and/or H2 (cimetidine and famotidine) antagonists were administered at 75% of the estimated peak shed blood volume (PSBV), a point preceding the rise in plasma histamine. Plasma histamine levels in all groups were similar throughout the time course of hemorrhagic shock. None of the histamine receptor antagonists affected the time of onset or the rate of decompensation. Suspecting that hypotension may alter the animal's response to histamine, we investigated the effect of exogenous histamine administration on MAP before and after hemorrhage. In unbled animals, bolus histamine infusions (.6 mg/kg) dropped the MAP by 62.0 +/- 2.7 mmHg, however, in animals bled to 40 mmHg, histamine dropped the MAP by 7.2 +/- 2.7 mmHg (p = .002). On the basis of the results of these two interventions, we conclude that histamine is not an important mediator of the cardiovascular collapse seen in the decompensatory phase of hemorrhagic shock in the rat.

An electronic menstrual cycle calendar: comparison of data quality with a paper version.

OBJECTIVES: This pilot study compared a prototype electronic menstrual calendar on a handheld computer with a paper calendar for data quality and participants' perceptions. DESIGN: Twenty-three women completed identical information about menstrual bleeding and symptoms using paper and electronic calendars for 1 month each. RESULTS: Use of the paper calendar resulted in more missing data than the electronic calendar for bleeding characteristics (13% vs. 4%) and symptoms (35% vs. 4%). The electronic calendar's ability to log data entries revealed retrospective entry for 61% of the data. Total data entry and cleaning time was reduced by 81% with the electronic calendar. Overall, participants preferred the electronic (70%) to the paper (22%) calendar. CONCLUSIONS: Data quality with conventional paper calendars may be poorer than recognized. The data-logging feature, unique to the electronic calendar, is critical for assessing data quality. Electronic menstrual calendars can be useful data collection tools for research in women's health.

Barriers that impede the adoption of pediatric information technology.

BACKGROUND: Information technology (IT) is a critical but underused component of health care. Many factors contribute to the inconsistent adoption of IT. OBJECTIVE: To review the literature to better elucidate barriers that are likely to affect the adoption of IT by pediatric professionals. DATA SOURCES: Manuscripts were found using a MEDLINE search combining the terms medicine, information systems, and technology transfer. I also obtained references cited by relevant articles. Finally, I explored the Internet using http://www.google.com and http://www.northernlight.com. STUDY SELECTION: Articles discussing barriers or factors affecting the adoption of IT were considered for inclusion. Articles unrelated to clinical IT were excluded. DATA SYNTHESIS: A variety of barriers exist that affect the adoption of useful technologies. Situational barriers include challenges imposed by the current national health environment, financial and legal risks associated with technology purchasing and use, and access to technology. The most significant barrier is that pediatric health care practitioners may lack the knowledge or training to use IT effectively. CONCLUSIONS: Although some barriers exist that may be challenging to overcome, other barriers, such as the lack of knowledge about the uses of IT, are imminently solvable. Efforts to overcome these barriers should begin in earnest and should include educating stakeholders in the care of children and adolescents, as well as improving the knowledge about various technologies available to support pediatric and adolescent health care.

Medical informatics and pediatrics. Decision-support systems.

Decision support is an important area of medical informatics research. Computer-based decision-support tools facilitate diagnosis and the management of patients after a diagnosis has been established. Diagnostic decision-support tools, such as Meditel, Quick Medical Reference, DXplain, Iliad, and PEM-DXP are potentially useful "expert systems." Other management-support tools, such as systems that use clinical practice guidelines to create reminders and alerts, also have been developed and evaluated. We do the following: (1) to provide an overview of diagnostic and management decision-support systems; (2) explore the background of and motivation behind these systems; (3) survey the uses of decision-support technology in office-based and inpatient pediatric practices; and (4) discuss the virtues and problems associated with some of these tools, and current controversies and future goals for computer-based decision support.

Metabolic and functional mapping of the neural network subserving inferior collicular seizure generalization.

The sensory-motor portion of the inferior collicular cortex is capable of seizure genesis that is characterized initially by coincident wild running behaviors and localized electrographic afterdischarge. With repeated stimulations, this seizure activity spreads into the forebrain, producing generalized tonic-clonic or myoclonic seizure activity. In order to characterize the neural network subserving this caudal-rostral seizure generalization, three mapping techniques were used: 2-deoxyglucose (2-DG) utilization, c-fos expression and local anesthetic microinjection. Kindled seizure generalization from the inferior collicular cortex produced a global increase in 2-DG accumulation, while relative 2-DG increases were found in the inferior collicular cortex, dorsal lateral lemniscus, dorsal central gray, peripeduncular nucleus, medial geniculate nucleus, substantia nigra, entopeduncular nucleus, ventroposterior and centromedian thalamus and tenia tectum, as well as the perirhinal, somatosensory and frontal cortices. Kindled seizure generalization also increased c-fos-like immunoreactivity (FLI) in the inferior collicular cortex, cuneiform nucleus, dorsal lateral nucleus of the lateral lemniscus, peripeduncular nucleus, caudal central gray, dentate gyrus of the hippocampus, rhinal fissure area of the perirhinal cortex and the frontal cortex. Microinjections of procaine into the amygdala, perirhinal cortex, entopeduncular nucleus, substantia nigra, peripeduncular nucleus, dorsal central gray, and pontine reticular nucleus all prevented generalized seizure behaviors, but had no effect on the wild running seizures. Conversely, procaine microinjection into the area of the cuneiform nucleus/pedunculopontine tegmental nucleus prevented the wild running seizure but did not block the generalized seizure activity. Neither wild running, nor generalized seizures were altered following procaine microinjections into the anterior thalamus, sub-thalamus, lateral hypothalamus, hippocampus or deep superior colliculus. Thus, specific forebrain sites form a widespread neural network that mediates the generalization of seizure activity from the inferior collicular cortex into the forebrain.

Quantifying the literature of computer-aided instruction in medical education.

PURPOSE: To characterize the literature about computer-aided instruction (CAI) as it relates to medical education. METHOD: A descriptive study using the Medline and ERIC databases, reviewing articles pertaining to CAI for medical professionals. The literature was evaluated with respect to type of article, journal, language, and year of publication. RESULTS: The search yielded 2,840 citations, 92% of which were in English. The number of journals with at least one citation was 747. Less than 5% of the 5,147 authors had three or more articles published in the CAI literature. Of the citations with abstracts, 60% were demonstrations of a CAI application, 11% were media-comparative studies, and 13% were analyses of the CAI field. While the pace of article publication increased markedly over time, the percentages of article types did not change significantly over time. Less than 10% of CAI articles appeared in core medical journals. CONCLUSION: Medical CAI is an increasingly popular topic of research and publication. However, these studies appear in journals with smaller circulations, are predominantly demonstration articles, and are generally written by authors with two or fewer publications. Evaluation articles remain less common. A series of analytic articles has appeared offering substantive suggestions for better research design. These suggestions appear to have gone unheeded. CAI investigators need be more aware of the gaps in the existing body of CAI publications, and the inherent difficulties of this type of research, if this literature is to move beyond this early stage of development.