Teaching basic principles of surgical technique using a placental model.

Surgical technique was taught to third-year medical students using the placenta as tissue for practice and to illustrate the proper use of surgical tools, using principles that promote accuracy, security and efficiency of manual control.

Feasibility of postpartum rapid hospital discharge: a study from a community hospital population.

We have examined the safety and efficacy of an early postpartum discharge program in 289 patients who were identified prior to delivery and counseled and educated for discharge 12 to 36 hours after delivery. A total of 55% of the study patients were able to be discharged early. There were 4.3% significant maternal problems and 3% significant neonatal problems identified in the first 72 hours after delivery by a nurse practitioner home visit. Significant maternal problems after 72 hours (10%) and neonatal problems (5%) were also found by follow-up visits. The hospital readmission rate was 1.8%. These incidences are consistent with other studies in the literature and suggest that some type of early follow-up of both the mother and infant should routinely accompany early postpartum discharge programs.

Developmental toxicity risk assessment: a rough sets approach.

A rough-sets approach was applied to a data set consisting of animal study results and other compound characteristics to generate local and global (certain/possible) sets of rules for prediction of developmental toxicity in human subjects. A modified version of the rough-sets approach is proposed to allow the construction of an approximate set of rules to use for prediction in a manner similar to that of discriminant analysis. The modified rough-sets approach is superior in predictability to the original form of rough-sets methodology. In comparison to discriminant analysis, modified rough sets (approximate rules) appear to be better in overall classification, sensitivity, positive and negative predictive values. The findings were supported by applying the modified rough sets and discriminant analysis on a test data set generated from the original data set by using a resampling plan.

Eliciting principles of hazard identification from experts.

National experts in the field of developmental toxicology were interviewed in order to elicit the principles, or rules-of-thumb, they use in determining if a compound or agent is likely to be a developmental hazard during pregnancy. Several levels of individual and cumulative consensus activity were carried out that resulted in consensus in 71 rules and partial consensus in an additional 24 rules of 145 rules initially elicited. Rules could be divided generically into those affecting the expert's confidence in a piece of scientific evidence and those determining the weight of importance of that evidence in deciding about hazard identification. Topically, the rules also divided into those about the general nature or characteristics of a compound, animal studies testing for an effect of the compound, and human reports about the presence of absence of developmental effects associated with the compound. Several conclusions about the methodology include the following: 1) expert systems must be based on the knowledge of more than one expert; 2) considerable human effort is expended in evaluating the certainty of scientific evidence before combining the evidence for problem solving; 3) how experts use evidence of different degrees of uncertainty in their decisions is a major area that is yet to be determined and that may greatly affect subsequent efforts in artificial intelligence; and 4) knowledge elicitation by interview has limitations but is a workable methodology for medical decision making.

Learning theory and knowledge structures in computer-aided instruction.

The development of computer-aided instructional (CAI) systems suffers from a lack of a cohesive theory of learning--how do students acquire and store knowledge? From studies of computer systems that learn and tutor, we can infer generic activities that appear to be integral parts of the learning process, such as aggregation, clustering, characterization, and storage for later retrieval. Learning is faster and more efficient if the goal of a task is made explicit. Hints should be given with the correct timing in relation to an objective so that students can advance in their own problem-solving strategies with the prerequisites in mind. The general form of a rule should usually be taught first, followed by exceptions and special instances. We review theories of learning associated with CAI that illustrate the classification of different types of knowledge. Rule-based (if-then) knowledge forms are represented in these theories, as are declarative and causal knowledge structures. Extracting the common themes from different classifications of knowledge may help us create better CAI.

Prediction of risk for human developmental toxicity: how important are animal studies for hazard identification?

To determine how developmental toxicity studies in animals can be used in human risk assessment, a data base was assembled from the literature. It included probable, suspected, unknown, and probably negative teratogenic or embryotoxic drugs and chemical compounds. For each of 175 substances, we recorded the results of any developmental toxicity testing in up to 14 animal species and any reports of mutagenicity or carcinogenicity. Logistic regression and discriminant analysis were used to predict a compound's effect in humans. A measure of the number of positive animal studies and bacterial mutagenicity were important predictors in both models, as were the specific results in hamsters and subhuman primates. The fact that a compound had been tested at all in subhuman primates was more important in predicting human risk than was the result itself. The methods used correctly classified the study compounds 63-91% of the time, depending upon how the suspicious and unknown compounds were treated. The models had a sensitivity of 62-75%, a positive predictive value of 75-100%, and a negative predictive value of 64-91%. These findings imply that studies in laboratory animals carry weight in predicting human developmental toxicity. The more animal species in which a compound is positive, the more likely it is to have a human effect, albeit not the same effect as in the animals. Clinicians should not ignore developmental toxicity tests in animals "because laboratory rats are not like humans."

Application of teaching and learning principles to computer-aided instruction.

Many authors of software providing computer-aided instruction (CAI) have no background in educational theories. This paper reviews teaching theories and ways in which instructional principles can be applied to CAI. While the lecture form of teaching has often been maligned, there are techniques for enhancing lectures that can also apply to CAI. Effective communication methods, both verbal and audiovisual, are as important in computer modules as they are in face-to-face teaching. The quality of interactive questioning and the nature and timing of feedback are critical to the success of instruction by computer. Appropriate feedback can improve retention, as can the use of proper distractors in multiple-choice questions. We present steps for developing a CAI learning module based on established principles of teaching and learning, as well as proper identification of educational goals.

Application of computer technology to reproductive endocrinology.

Data manipulation and information management activities are as central to physicians as writing is to the literary profession. It is not surprising that the computer, as an information tool, has become important and accepted in many aspects of our professional lives. Computer applications can significantly help in daily patient care activities as well as serve as instruments for advancing and managing medical knowledge. Even if the rate of computer technology change slows down from its exponential increase in the last decade, useful software applications will continue at the same or faster rate since they do not now, fully utilize existing hardware features. This presents an exciting future for all information management, decision-rich professions.

Information management needs of the obstetrician-gynecologist--a survey.

A random sample survey of members of The American College of Obstetricians and Gynecologists (ACOG) was conducted to ascertain the extent to which computer technology was being used by the members, and what further computer services and applications were needed. Computers were used by 38% of the members, with an additional 13% planning on getting a computer within the year. An average of 48% of the members had no plans for computerization, although this number was lower (29%) for physicians 36-45 years of age. There was no significant variation of use by physician sex or type of practice (office- versus non-office-based). Word processing and financial management were the most frequently used computer applications; clinical patient care tasks were used much less frequently and were presumably less available, because software for these tasks was also highly desirable. The most desired information services were uniform coding and terminology, high-risk patient management, electronic access to full-text obstetric and gynecologic data bases, and online clinical management protocols. Prescription writing, patient recall by drug, and drug inventory computer applications were among the least requested. Several educational, project development, communication, and member service strategies have been formulated to integrate medical information management activities for ACOG members.

Microcomputer-aided instruction for ob-gyn education.

PC-CAI is a computer program that presents text characters from a word-processed file. The software was created to allow rapid authoring of computer-aided-instruction modules or multiple choice tests that give explanation and feedback to the student about their choice of responses. The program is IBM-PC/XT/AT compatible under MS-DOS. It is used in the Department of Obstetrics and Gynecology for medical students to supplement faculty lectures and also to administer pre- and post-tests to those students. The program is additionally used to create practice tests for our residents to prepare for their in-training exams. The software's main forte is to create multiple choice question modules, with feedback and explanations, that serve as learning tools rather than just as testing tools. Its use has enabled our department to create a comprehensive set of teaching modules in a relatively short period of time. These modules are easily modifiable as medical concepts or teacher emphasis changes.

Pharmacokinetics and expert systems as aids for risk assessment in reproductive toxicology.

A minimal approach to risk assessment in reproductive toxicology involves four components: hazard identification, hazard characterization, exposure characterization, and risk characterization. In practice, risk assessment in reproductive toxicology has been reduced to arbitrary safety factors or mathematical models of the dose-response relationship. These approaches obscure biological differences across species rather than using this important and frequently accessible information. Two approaches that are formally capable of using biologically relevant information (pharmacokinetics and expert system shells) are explored as aids to risk assessment in reproductive toxicology.

Computer applications in obstetrics.

The potential impact of the computer on the practice of obstetrics has long been recognized and is slowly being realized. Computers are already essential in many administrative aspects of obstetrics and indispensable in data storage and analysis for clinical research. Emerging applications include computer systems for taking the perinatal history, storage and on-line interpretation of fetal monitor tracings, information retrieval for case management and research purposes, and computer-assisted instruction. Future applications offer possibilities of computerized consulting for support of obstetric decisions and sophisticated case simulations for continuing education.

Family history of diabetes mellitus and oral glucose tolerance testing criteria.

A review of 185 obstetrical patients, having a family history of diabetes mellitus without medical history of glucose intolerance in the non-pregnant state was conducted. A 3-hour 100-g oral glucose tolerance test was performed on all patients between 20 and 34 weeks of gestation. According to O'Sullivan's criteria for glucose tolerance testing, normal glucose tolerance occurred in 89.7%, while Class A diabetes was identified in 10.3% of patients tested. 3.8% of the study population fulfilled the O'Sullivan criteria for abnormal glucose intolerance and required insulin treatment during pregnancy. The Division of Perinatal Medicine at Duke University has traditionally defined the abnormal glucose tolerance test at glucose values lower than O'Sullivan's internationally accepted criteria. An intermediate group, having abnormal glucose values according to the Duke criteria, was classified as "Carbohydrate Intolerance", comprised 32.4% of the patients tested and were managed identically to O'Sullivan Class A Diabetes. Analysis or perinatal outcome, including macrosomia, birth trauma and neonatal morbidity, revealed that Carbohydrate Intolerance patients fulfilling O'Sullivan criteria, being similar to patients with 'normal' GTT test results. Patients having a family history of diabetes mellitus, appeared as a group to be at increased risk for macrosomia, fetal distress and cesarean delivery, compared with the general population.