Reasons for declining computerized insulin protocol recommendations: application of a framework.

Clinical decision support systems (CDS) can interpret detailed treatment protocols for ICU care providers. In open-loop systems, clinicians can decline protocol recommendations. We capture their reasons for declining as part of ongoing, iterative protocol validation and refinement processes. Even though our protocol was well-accepted by clinicians overall, noncompliance patterns revealed potential protocol improvement targets, and suggested ways to reduce barriers impeding software use. We applied Rita Kukafka and colleagues' (2003) IT implementation framework to identify and categorize reasons documented by ICU nurses when declining recommendations from an insulin-titration protocol. Two methods were used to operationalize the framework: reasons for declining recommendations from actual software use, and a nurse questionnaire. Applying the framework exposed limitations of our data sources, and suggested ways to address those limitations; and facilitated our analyses and interpretations.

A frame-based representation for a bedside ventilator weaning protocol.

We describe the use of a frame-based knowledge representation to construct an adequately-explicit bedside clinical decision support application for ventilator weaning. The application consists of a data entry form, a knowledge base, an inference engine, and a patient database. The knowledge base contains database queries, a data dictionary, and decision frames. A frame consists of a title, a list of findings necessary to make a decision or carry out an action, and a logic or mathematical statement to determine its output. Frames for knowledge representation are advantageous because they can be created, visualized, and conceptualized as self-contained entities that correspond to accepted medical constructs. They facilitate knowledge engineering and provide understandable explanations of protocol outputs for clinicians. Our frames are elements of a hierarchical decision process. In addition to running diagnostic and therapeutic logic, frames can run database queries, make changes to the user interface, and modify computer variables.

Pre- and Postharvest Treatments to Control Green Mold of Citrus Fruit During Ethylene Degreening.

Two approaches, fungicide applications to trees before harvest and drenching fruit after harvest, were evaluated to minimize postharvest green mold, caused by Penicillium digitatum, particularly among fruit subjected to ethylene gas after harvest, a practice termed "degreening" that eliminates green rind color. Preharvest applications of thiophanate methyl (TM) controlled postharvest green mold consistently. In five tests, green mold among degreened orange fruit was 16% when TM was applied 1 week before harvest; whereas, among fruit not treated, the incidence was 89.5%. Thiabendazole (TBZ) applied to harvested fruit in bins before degreening also was very effective. TBZ effectiveness was enhanced by mild heating (41°C), adding sodium bicarbonate, and immersing fruit, rather than drenching them, with the solution. With these measures, an isolate of P. digitatum with a high level of TBZ resistance was significantly controlled. In semicommercial tests with naturally inoculated fruit, TBZ and sodium bicarbonate treatment reduced green mold incidence from 11% among untreated orange fruit to 2%. TBZ residues in lemon fruit at 41°C were about twice those treated at 24°C. Neither TM before harvest nor TBZ and sodium bicarbonate applied after harvest influenced green color removal during degreening of orange fruit. Sodium bicarbonate slightly reduced the rate of lemon color change.

The response of adult rat sertoli cells, immortalized by a temperature-sensitive mutant of SV40, to 1,2-dinitrobenzene, 1,3-dinitrobenzene, 2,4-dinitrotoluene, 3,4-dinitrotoluene, and cadmium.

In this study we test the hypothesis that immortalized adult rat Sertoli cells respond to known testicular toxins in a similar manner to Sertoli cells tested in vivo and in primary culture. This cell line was developed by immortalizing adult rat Sertoli cells with the temperature-sensitive mutant of SV40, ts255, such that the cells proliferate at the permissive temperature of 33 degrees C but express differentiated characteristics at the nonpermissive temperature of 40 degrees C. Confluent monolayers, grown at 33 degrees C or 40 degrees C, were exposed to a range of concentrations of dinitrobenzene (DNB) or dinitrotoluene (DNT) isomers or to cadmium chloride. Cellular response was assessed by neutral-red cell viability assay and ultrastructural changes. Cells grown at 40 degrees C were sensitive to lower concentrations of each toxicant than were cells grown at 33 degrees C. 1,2-DNB was more toxic than 1,3-DNB, and 3,4-DNT was more toxic than 2,4-DNT, as judged by the neutral-red cell viability assay. Ultrastructurally, cells treated with 1,2-DNB or 2,4-DNT showed increased numbers of autophagic vesicles compared to controls. Intercellular penetration of ruthenium red demonstrated breached tight junctions in 1,2-DNB and cadmium-treated cells. From these observations, we conclude that this cell line can serve as a model for studying toxic mechanisms in adult Sertoli cells.

Quantification of the Toxicity of Aqueous Chlorine to Spores of Penicillium digitatum and Geotrichum citri-aurantii.

Chlorine toxicity to Penicillium digitatum and Geotrichum citri-aurantii, causes of green mold and sour rot of citrus, respectively, was quantified. In 3% wt/vol NaHCO3 containing 200 µg free chlorine per ml at pH 8.3, 95% of P. digitatum spores died (LT95) by 180 s at 5°C, while only 32 s were required at 24°C. The LT95 of G. citri-aurantii arthrospores was 108 and 31 s at 5 and 24°C, respectively. Mortality slowed 2- to 4-fold for each unit of increase from pH 7 to 10. The LT95 of P. digitatum spores in 200 µg free chlorine per ml at 24°C at pH 7, 8, 9, and 10 was 13.2, 19.1, 29.4, and 88.4 s, respectively. The LT95 of G. citri-aurantii at pH 7, 8, 9, and 10 was 3.0, 12.6, 56.6, and 114 s, respectively. Models were prepared describing mortality. Brief immersion in 200 µg free chlorine per ml reduced viable spores of P. digitatum and G. citri-aurantii from 106 to 103 spores per lemon, and naturally occurring yeast and molds from 106 to 104 CFU. In fruit wound-inoculated and immersed 24 h later in water, 4,000 µg free chlorine per ml, or 3% wt/vol NaHCO3, green mold occurrence after storage was 98.5, 68.3 and 7.5%, respectively.

Demographic differences in body composition of Navy and Marine Corps personnel: findings from the perception of wellness and readiness assessment.

With the recent increase in women's representation in the military, baseline physical measurement data are needed to help set appropriate accession and retention standards and to design useful prevention and intervention programs in the areas of physical fitness and health. This study incorporated several body composition indices to obtain anthropometric data for a representative sample of 1,292 active duty Navy and Marine Corps women and men. It also assessed the extent to which personnel met weight-for-height and body fat standards. The prevalence of overweight was considerably lower among Marine Corps women compared with Navy women and was slightly less for Marine Corps men compared with their Navy counterparts. Between one-fifth and one-third of military personnel exceeded Navy/Marine Corps weight-for-height standards. Navy women tended to meet weight standards more often than Navy men. Fewer Marine Corps women than men were overweight, but more exceeded their weight-for-height standards.

Fantasies of the unborn among pregnant women.

PURPOSE: This investigation sought to describe how pregnant women fantasize about their unborn children. METHODS: A questionnaire using one open-ended question was given to 210 pregnant women in childbirth education classes. The final sample was 184. Content and matrix analyses were used to identify evidence of fantasy patterns in primiparas and multiparas, as well as patterns among the three gestational trimesters. RESULTS: Results indicate that fantasies have a developmental component across gestational trimesters and differ between multiparas and primigravidas. Ten major themes were derived. IMPLICATIONS: Routine assessments of prenatal fantasy might help to promote healthy behaviors in pregnant women and enhance positive interpersonal relationships between the provider and client. Future research is needed to discern the impact of antenatal fantasies on maternal role development.

Form follows function: occlusion based rationale for esthetic dentistry.

Esthetic dentistry is one of the prime essential areas in dentistry today. The purpose of this article is to address the dependent relationship between excellent esthetics and optimum occlusion. Occlusal objectives must be addressed and achieved. If one is to expect to recreate ideal esthetics, one must first thoroughly investigate, diagnose, and establish an ideal occlusal scheme. The case study within this article revisits the most imperative principle with regards to esthetics and that is: form always follows function.

New computer-based tools for empiric antibiotic decision support.

Since 1995 we have been developing a decision-support model, called Q-ID, which uses a series of infectious disease knowledge bases to make recommendations for empirical treatment or to check the appropriateness of current antibiotic therapy. From disease manifestations and risk factors, a differential diagnosis for the patient is generated by a diagnostic medical expert system. The resulting probability of each: disease is multiplied by the expected benefit in improved mortality and morbidity from optimal antibiotic treatment of each disease. To generate empirical treatment recommendations, site-specific data on sensitivity to antibiotics of each organism is used as an estimate of the likelihood of achieving maximum benefit for each disease on the patient's differential. Combining this data with drug and patient specific factors, the model recommends the antibiotic(s) most likely to produce the optimal benefit in this patient with the least risk and expense. In this paper the model is described, excerpts from each of the knowledge bases are presented, and performance of the model in a real case is shown for illustration.

Qualitative analysis of temporal information in Iliad: implications for linking Iliad to an electronic medical record as a knowledge server.

In linking Iliad to an electronic medical record (EMR) as a knowledge server, our objective is to convert the date and time stamped data from the EMR to the temporal representations existing in the Iliad knowledge base. First, an empirical analysis of Iliad's temporal information content is described: categorizing, estimating the amount (22%), and offering a temporal template to canonically represent it. Second, we analyze the effect of history and physical examination temporal information on the diagnostic performance of the system using data from 241 real cases. Third, we discuss knowledge engineering mapping techniques to convert time information found in EMRs. We conclude that the Iliad system includes a large amount of explicit and implicit time information and this information improves the system's diagnostic accuracy, both in terms of diagnosis ranking and confidence.

Life event timing synchrony.

This paper traces the evolution of "life event timing" with particular emphasis on the derived concept, "life event timing synchrony." Life event timing synchrony refers to the degree to which an experience is perceived as harmonious and congruent with an individual's temporal expectations. Pregnancy serves as an illustration for application. Suggestions for further theoretical and empirical development are provided.

Reasons for employment or non-employment during pregnancy.

Although women's pattern of employment during pregnancy has markedly changed in the last 30 years, no research has explored the basis of contemporary women's decision making regarding employment during pregnancy. Conceptualizing pregnancy within a life span developmental perspective of adulthood, we used descriptive statistics and content analysis on data from 210 pregnant women to identify factors that influence employment decisions during pregnancy. Intrinsic reasons for working during pregnancy included self-actualization, escape from home, employment identity, and interpersonal contact. Extrinsic reasons for working included money, financial obligations, and employment setting compatibility. Intrinsic reasons for not working during pregnancy included pregnancy-related limitations, home identity, complexity, and family responsibilities. Extrinsic reasons for not working included financial juggle, job availability, and employment setting incompatibility. The results form a basis for anticipatory guidance recommendations for pregnant women.

Implementation of practice guidelines in a clinical setting using a computerized knowledge base (Iliad).

We present the implementation of the indications for surgery for three surgical operations--cholecystectomy, cataract extraction, and knee arthroscopy--in a medical expert system, called Iliad. This implementation operates in the preauthorization service of IHC Health Plans (an insurance company in Salt Lake City) as a basis for reimbursement of services. Patient data collection forms, derived from Iliad knowledge base, were used by 13 participating surgeons to document the objective patient observations that justify the surgery and, then were faxed to IHC where a trained nurse input the data in Iliad. Iliad's decisions and reports on any deviations from guidelines are communicated back to the care provider. The study evaluates the impact of the computerized implementation on process, as measured by a questionnaire, and on outcome as measured by rate of approvals, documentation level, rate of requests, and average cost. The prospective implementation of the computerized guidelines has performed reliably, has been perceived as a preferred alternative to the old preauthorization system, and, most importantly, has enhanced significantly the level of documentation permitting evaluation and determination of appropriateness before surgery.

Uncertainty in illness theory: a replication of the mediating effects of mastery and coping.

The purpose of this investigation was to replicate a test of the mediating functions of mastery and coping and to determine whether the relationships found in the initial test of the model would hold with a sample more heterogenous than the original sample. One hundred women receiving treatment for gynecological cancer participated in the investigation. Of the 14 relationships in the model, only 5 replicated significant paths and had overlapping confidence intervals. Two moderators were proposed to explain the differences between the initial and replication tests of the model and to improve the specificity of the theory.

Uncertainty in gynecological cancer: a test of the mediating functions of mastery and coping.

The purpose of this study was to test a portion of the uncertainty in illness model to determine whether mastery would be strengthened or weakened under conditions of uncertainty, and to test the ability of mastery and coping to function as mediators in the model. Mastery was proposed to mediate the relationship between uncertainty and the appraisal of danger and opportunity. Coping was proposed to mediate the relationships between danger or opportunity and emotional distress. Data were collected on a sample of 131 women receiving treatment for gynecological cancer. Findings support mastery as weakened under conditions of uncertainty and functioning as a situationally specific personality factor. Mastery was a significant mediator of the relationship between uncertainty and the appraisal of danger and opportunity; although the mediation effect for the relationship between uncertainty and danger was stronger. While two coping strategies were found to function as significant mediators between danger or opportunity and emotional distress, the mediation effect was very small.

Iliad training enhances medical students' diagnostic skills.

Iliad is a computerized, expert system for internal medical diagnosis. The system is designed to teach diagnostic skills by means of simulated patient case presentations. We report the results of a controlled trial in which junior students were randomly assigned to received Iliad training on one of two different simulated case mixes. Each group was subsequently tested in both their "trained" and "untrained" case domain. The testing consisted of computerized, simulated patient cases for which no training feedback was provided. Outcome variables were designed to measure the students' performance on these test cases. The results indicate that students made fewer diagnostic errors and more conclusively confirmed their diagnostic hypotheses when they were tested in their trained domain. We conclude that expert systems such as Iliad can effectively teach diagnostic skills by supplementing trainees' actual case experience with computerized simulations.