Stevens-Johnson-type reaction with vancomycin treatment.

To report a case of Stevens-Johnson syndrome caused by vancomycin. Stevens-Johnson syndrome is an acute mucocutaneous process characterized by epidermal and mucosal desquamation. Its pathogenesis is poorly understood. Mortality rates have ranged from 30 to 100 percent. We describe a case of Stevens-Johnson syndrome related to the use of vancomycin in a 71-year-old woman with rheumatoid arthritis receiving treatment for an infected cervical fusion site. Classic "target" lesions distributed throughout the trunk and extremities along with erosive lesions involving the oral and vaginal mucosae were observed in this patient. A number of agents have been implicated in the etiology of Stevens-Johnson syndrome. Serious cutaneous reactions to vancomycin, however, have been uncommon. Cessation of vancomycin treatment in our patient led to eventual resolution of her symptoms. Vancomycin is a potential causative agent of Stevens-Johnson syndrome.


Dobutamine-induced fever.

To report a case of dobutamine-induced fever. A 71-year-old woman with congestive heart failure who developed a fever after receiving dobutamine during two separate hospital admissions. Other possible causes of the fever during the first admission included relapse of staphylococcal sepsis and drug fever from vancomycin or metoclopramide. However, rechallenge with dobutamine on a subsequent admission demonstrated a highly probable relationship between dobutamine and fever. A strong temporal relationship between dobutamine and fever was noted during the patient's second admission and the case was not complicated by other new medications. No underlying infectious or noninfectious cause of the fever was found. Therefore, when patients receiving dobutamine become febrile, dobutamine should be considered as a possible cause.


Aspirin for the prevention of vascular death in women.

To review current information relevant to the use of aspirin for preventing vascular death in women, and to provide recommendations based on this information. References from pertinent articles are identified throughout the text. Based on current information, low-dose aspirin is not recommended as primary prevention for cardiovascular death in women; efforts are better focused at promoting risk-factor reduction. Low-dose aspirin is recommended for reducing further cardiovascular morbidity and mortality in women with known cardiovascular disease. Women presenting with unstable angina or myocardial infarction should receive aspirin 325 mg as soon as the diagnosis is confirmed, and this dosage should be continued on a chronic basis. Women who have experienced transient ischemic attacks or ischemic stroke should receive aspirin 1000 mg/d, with a subsequent dosage reduction to 325 mg/d in patients who do not tolerate the higher dose. Current recommendations are based on the results of studies that involved few women. Further investigation of antiplatelet agents for primary and secondary prevention of vascular death in women is needed.


Hirudins: antithrombin anticoagulants.

To review the chemistry, pharmacology, available clinical data, and adverse effects of the hirudin anticoagulants. A MEDLINE search and a review of recent scientific abstracts was conducted to identify pertinent literature. Focus was placed on studies conducted in humans. Because hirudin is still an investigational agent, however, relevant animal data, particularly pharmacokinetic studies and studies of preclinical efficacy, were also selected. Data from both human and animal studies were evaluated; emphasis was placed on human trials. Hirudin has demonstrated potent anticoagulant effects. Although hirudin could have a significant impact on the therapeutic management of patients requiring anticoagulant therapy, only a limited number of human studies have been published to date. Trials comparing hirudin and heparin in specific patient populations are still ongoing. Although still in clinical trials, hirudin is a unique agent that may represent a breakthrough in anticoagulant therapy. The specific role that this agent will play in the management of patients has yet to be determined.


Use of fish oil to prevent coronary angioplasty restenosis.

To review the literature investigating the use of fish oil in preventing restenosis postangioplasty (RPA). An Index Medicus and bibliographic search of the English-language literature pertaining to the use of fish oil in preventing RPA. The key terms used were fish oil, angioplasty, and eicosapentaenoic acid. The results of all trials, including abstracts, that were obtained are reviewed and critiqued. Restenosis of a coronary vessel at the site of angioplasty occurs 30-40 percent of the time. Because fish oil has been theorized to prevent atherosclerosis and because atherosclerotic-like processes are theorized to be involved in RPA restenosis, fish oil has been studied to determine whether it can prevent RPA. Results of such trials have been mixed. Some have observed a reduction in the number of patients with angiographic or clinical evidence of restenosis. Two trials have failed to observe such an effect. Reasons for the differences are unknown. Possible explanations include differences in study design, endpoint parameters, definition of restenosis, and dosing methods of the fish oil. Bleeding was not of significant concern in any of the trials, even when fish oil was combined with antiplatelet therapy. Fish oil may be considered for use in patients to prevent RPA. It probably should be continued for only six months following the procedure. Current data suggest that at least 3 g/d of eicosapentaenoic acid and 1 g/d of docosahexaenoic acid should be used. If possible, therapy should be started as soon as it is known that angioplasty will be performed or at least as soon as possible following the procedure. Many patients may not be able to tolerate fish oil because of its gastrointestinal effects.


Impact of drug use evaluation upon ambulatory pharmacy practice.

To review the expansion of ambulatory drug use evaluation (DUE). A description of ambulatory DUE characteristics and methodology is included. In addition, DUE computer usage, documentation concerns, and future research issues are addressed. A MEDLINE search was used to identify pertinent literature, including reviews. Primary and secondary literature describing ambulatory DUE was selected. Articles describing inpatient DUE were excluded. Rigorous studies evaluating current ambulatory DUE programs are limited, but the available literature and a description of existing program characteristics are included. All studies available at the time of publication were reviewed. Ambulatory DUE can provide useful information to assist in providing pharmaceutical care. The Omnibus Budget Reconciliation Act of 1990 has prompted an expansion of DUE programs, and most of the formalized programs are retrospective in design. Prospective programs provide online, patient-specific drug use assessment whenever new prescriptions are entered into point-of-service databases. Although more well-designed evaluations of existing ambulatory DUE programs are needed, initial results indicate these programs may be extremely useful in identifying significant medication therapy problems and improving patients' drug therapy.


Effect of xanthine-related compounds on a theophylline assay using theophylline oxidase.

This study investigated a new, nonimmunologic, enzymatic-based theophylline assay for the possible interference of a clinically achievable serum theophylline concentration by four xanthine-related compounds: pentoxifylline, 1-methylxanthine, allopurinol, and oxypurinol. The enzyme theophylline oxidase is used in this assay kit to convert theophylline to 1,3 dimethyluric acid in the presence of cytochrome C. Cytochrome C is reduced to ferrocyte C, which is then measured by ultraviolet spectrophotometry at one minute and again at five minutes. The rate of appearance of ferrocyte C over this time is then related to a one-point 20-micrograms/mL (111-mumol/L) theophylline standard provided with the kit and the concentration of theophylline is calculated. Xanthine-related compounds have the potential to interact with theophylline oxidase via: (1) structural similarity, and (2) inhibition of xanthine oxidase, which increases theophylline metabolite concentrations. Human serum was spiked with known, therapeutically achievable concentrations of pentoxifylline, 1-methylxanthine, allopurinol, and oxypurinol, both alone and in combination with theophylline in a concentration of 15 micrograms/mL (83.3 mumol/L). Two controls were used: human serum and human serum spiked with theophylline. Data were analyzed statistically with ANOVA, and clinically with +/- 10 percent control criteria. Means (+/- SEM) for the control samples were 2.0 (0.2) micrograms/mL for serum alone and 15.3 (0.3) micrograms/mL for theophylline-spiked serum. For the test specimens, the results ranged from 2.3 to 2.8 micrograms/mL and from 13.9 to 16.6 micrograms/mL when xanthine-related compounds were added to serum without and with theophylline, respectively. The results were not statistically or clinically significant for the four xanthine-related compounds at the concentrations studied.


Value of community pharmacists' interventions to correct prescribing errors.

The purpose of this analysis was to estimate the economic value created by community pharmacists who routinely screen for and correct prescribing-related problems during the course of their dispensing activities. Three expert judges evaluated the documented interventions of community pharmacists practicing in five states. The judges agreed that 28.3 percent of the identified problems could have resulted in patient harm had the pharmacist not intervened to correct the problem. The direct cost of medical care that was avoided as a result of pharmacists' intervention activities was estimated to be $122.98 per problematic prescription, or +f42.32 per each new prescription order that was screened during the study. Clinical pharmacy services can and do create significant value by enhancing the achievement of positive patient outcomes and by avoiding negative outcomes. Research to develop reliable methods for measuring and monitoring the value of clinical pharmacy services must continue. Mechanisms must be created to encourage and reward pharmacists who consistently provide services that add measurable value to patient care.


Costs of pharmaceutical care: can the profession do anything?

To review some of the factors that influence the cost of pharmaceuticals and the delivery of pharmaceutical care as well as some possible measures for decreasing these costs. Clinical studies have been selected to illustrate factors that may add to the overall cost of pharmaceutical care. Because of the perceived problems resulting from the introduction of new, expensive pharmaceuticals, possible means of controlling the costs of individual products are discussed. In addition, recommendations for achieving cooperation between pharmaceutical manufacturers and pharmacy practitioners in demonstrating the cost-effectiveness of new products are provided.


Survival after repair of postinfarction ventricular septal defects in patients over the age of 70.

Ventricular septal defect (VSD) is an infrequent but extremely serious complication of myocardial infarction. Operative mortality rates tend to be higher in the elderly population; however, long-term follow-up has not been specifically studied. It is, therefore, important to assess not only the early but also the long-term results of VSD repair in patients over 70 years of age to determine its value for the elderly patient. Between June 1968 and May 1991, 86 patients who experienced a myocardial infarction underwent surgical repair of an infarct related VSD at the Massachusetts General Hospital (MGH). Group I (n = 57) includes those patients younger than 70 years, and group II (n = 29) represents those patients age 70 years and older. Follow-up of hospital survivors ranged from 1 month to 24 years and was compiled in April and May, 1991. Three patients were lost to follow-up (4%), and these were younger than 70 years of age. There were no differences in the values of the preoperative variables for the younger and older groups with respect to sex, concomitant procedures performed (bypass vs no bypass), use of an intra-aortic balloon pump (IABP), location of VSD, presence of shock, total hospital days, or days between infarction and operation. There was, however, a difference between the two groups relative to the era when surgery was performed. More patients over the age of 70 underwent surgery after 1978 than before 1978 (p = 0.0012). The majority of survivors are in New York Heart Association (NYHA) Class I or II, and there was no difference between the younger and older groups in functional class at the time of follow-up (83.3% vs 91.7% of survivors in Class I or II, respectively). Using the generalized Wilcoxon test to analyze these survival data, there was no apparent difference in long-term survival (p = 0.97) when comparing the two age groups. The mean follow-up period was 77.02 months for the younger group and 80.52 months for the older group. The fact that more older patients were repaired after we had significant experience in the surgical management of patients with VSDs probably accounted for our excellent results in the older age group. Our data reveal that patients over the age of 70 can expect excellent long-term survival, with over 90% of these survivors remaining in NYHA Functional Class I or II.


Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure.

Replacement of the aortic arch during repair of either extensive aortic aneurysmal disease or aortic dissection can be a major undertaking. Borst introduced an "elephant trunk" technique whereby a tubular aortic graft prosthesis was inserted into the distal aorta while repairing the ascending aorta and aortic arch. The distal elephant trunk prosthesis was then used for a second stage operation that involved replacement of sections of the distal aorta. Since then, a few problems have been encountered with the standard elephant trunk procedure and this has led to a modification of the elephant trunk technique, which enables a more accurate and secure distal aortic arch anastomosis to be performed. Using the standard technique described by Borst, the surgeon has to suture in the groove between the tubular graft and the aortic wall, which can increase the risk that torsion on the suture needle will tear the aortic wall resulting in aortic rupture. Indeed, this complication has been noted in the postoperative period when performing the standard technique. Subsequently, the technique was modified with inversion of the graft in itself, placement of the graft in the descending aorta, and performance of the distal anastomosis using a technique similar to that described by Griepp. This has improved the ease of performing the procedure and the results of the technique such that a better than 90% survival rate can be expected for the first and the second stage repairs.


Technique of combined heart-lung transplantation.

Heart-lung transplantation was, for many years, conceptualized as a possible treatment for patients with combined end-stage cardiac and pulmonary disease. As experience grew with heart transplantation, particularly in the 1970s, the difficulties of performing the orthotopic operation in patients with fixed pulmonary hypertension became apparent. This further impetus for combined heart-lung transplantation led to successful animal experiments in the late 1970s, and the first successful heart-lung transplant operation was performed in 1981. There has been significant evolution in the operative technique for the recipient operation, with emphasis on preservation of the phrenic, vagal, and recurrent laryngeal nerves and on meticulous hemostasis, with particular attention to the bronchial vessels of the posterior mediastinum. Donor procurement is of critical importance to the success of the operation, and criteria for donor selection have been well established. Lung preservation remained, for many years, a significant limitation, but current techniques involving the use of prostaglandin E1 have led to safe distant procurement with ischemic times up to 6 hours. The heart-lung transplant operation remains an effective modality for the treatment of patients with congenital heart disease, primary pulmonary hypertension, chronic obstructive pulmonary disease, and cystic fibrosis.


Surgical significance of morphological variations in the atrial septum in atrioventricular septal defect for determination of the site of penetration of the atrioventricular conduction axis.

The morphological variation in the recognized landmarks for the atrioventricular conduction system was studied grossly in 94 hearts with atrioventricular septal defect, assessing 20 hearts with normal atrioventricular septation as a control. In all the hearts with intact atrioventricular septal structures, the tendon of Todaro demarcated the superior boundary of the triangle of Koch. In hearts with atrioventricular septal defect, however, the landmarks for the conduction axis made up a separate nodal triangle. The tendon of Todaro, along with a bridging tendon not found in the normal heart, were variably developed in hearts with atrioventricular septal defect and formed a further triangle unrelated to the axis for atrioventricular conduction. The opening of the coronary sinus was also variable in its location and size. It was the location of the inferior bridging leaflet as it crossed the ventricular septum that was the best surgical landmark to the site of penetration of the atrioventricular conduction axis.


Technical considerations for coronary artery bypass without cardioplegia.

Coronary artery bypass without cardioplegia remains the preferred technique at many centers around the world. This report describes in detail a technique that emphasizes intermittent cross-clamping of the aorta at mild hypothermia (30 degrees C). Since coronary bypass procedures require brief interruptions of coronary blood flow only for the distal anastomoses, the duration of myocardial ischemia with this technique is not prolonged by unexpected changes in the operative plan. Many bypass grafts can also be carried out without cross-clamping of the aorta by using local control of the coronary arteries. The increasing number of elderly patients with atherosclerotic aortas that cannot be safely clamped makes it helpful for all cardiac surgeons to be familiar with noncardioplegic techniques.


Hypothermic fibrillatory arrest for coronary artery bypass grafting.

Hypothermic fibrillatory arrest is a technique of myocardial preservation that has a long history of use in cardiac surgery. Numerous studies have documented its efficacy in various subgroups of patients with coronary artery disease. This report reviews the research support of the tenets of the technique and reports the results with its utilization in 2,801 consecutive patients having isolated myocardial revascularization.


Coronary artery surgery without cardiopulmonary bypass: usefulness of the surgical blower-humidifier.

Coronary artery bypass surgery can be performed without cardiopulmonary bypass (CPB). Bleeding obscuring the operative field and hemodilution of shed blood with irrigating saline are some of the drawbacks of this technique. We report the use of a newly developed surgical blower-humidifier (custom made [Research Medical, Inc.]) for improved visualization and facilitation of coronary artery surgery without CPB.


Konno procedure for congenital aortic stenosis with a single coronary artery from the left coronary sinus.

A right coronary artery originating from the left coronary sinus and traversing anteriorly is thought to be one of the contraindications for a Konno aortoventriculoplasty in congenital aortic stenosis because this procedure necessitates incision of the right ventricular outflow tract. The case of a 5-year-old girl with congenital aortic stenosis associated with a single coronary artery, successfully treated surgically by the Konno procedure and right coronary artery reimplantation, is reported. Preoperatively there was a pressure gradient between the left ventricle and the ascending aorta of 109 mmHg, which disappeared postoperatively. A postoperative angiography showed a patent right coronary artery.


Simplified techniques of valve replacement.

After an extensive trial of many different suture techniques for implanting valvular prostheses, we have recently returned to using a simple, continuous suture of monofilament polypropylene. We believe this technique has many theoretical and practical advantages. Valvular implantation takes less time and is even more secure than when individual sutures are used. In addition, the need for porous felt pledgets, which may harbor bacteria, is eliminated. This simple technique facilitates implantation in the mitral and aortic positions.


Triiodothyronine (T3) and cardiovascular therapeutics: a review.

Hypothyroidism is associated with an abnormal hemodynamic state characterized by decreased heart rate, stroke volume, output, and contractility, and increased systemic vascular resistance. Since cardiopulmonary bypass (CPB) and surgical stress can induce profound decreases in triiodothyronine (T3) levels, the hemodynamic consequences of "stress-induced" hypothyroidism and T3 repletion are of increasing clinical interest. Available data generally support the likelihood of a beneficial effect associated with T3 replacement in brain-dead organ donors and in cases of low cardiac output following CPB. Although hypotheses have been advanced to account for these salutary effects, the mechanism by which T3 may augment hemodynamic performance has not been precisely defined, particularly in the acute setting. Although additional research is needed to clarify these and other issues, preliminary findings with T3 replacement indicate that such investigation is warranted.


Ovum donation: ethical and legal aspects.

The newer technologies of assisted reproduction offer the infertile couple a wide spectrum of choices according to their specific problem. A relatively newer technique is that of ovum donation, whose technology is now well established. However, as with other newer technologies, it has given rise to new dimensions of ethical and legal issues which have to date not been fully appraised. It is very difficult to find a legal consensus under international umbrella to the specific issues involved in ovum donation. This is due to the different cultural, religious, and time influence atmosphere prevailing in the various parts of the world. Each society should develop its own statutes on ovum donation. A frame of ethical guidelines should be established by international organizations that may help each society issue its own regulations.


Prediction of nuclear maturity from cumulus-coronal morphology: influence of embryologist experience.

A majority of in vitro fertilization (IVF) programs continues to evaluate oocyte maturity on the basis of cumulus-coronal morphology (CCM) even though marked asynchrony has been reported between CCM and nuclear maturity. This study was designed to examine changes in embryologists' ability to correctly predict nuclear maturity from CCM as a function of increasing experience. Nuclear maturity was assessed by inverted microscopy with a modified spreading technique at follicular aspiration. A second objective was to determine the percentage of oocytes which displayed asynchrony between CCM and nuclear maturity as assessed by embryologists with extensive experience in oocyte maturity evaluation. The three participating embryologists had directly evaluated 1304, 75, and 0 oocytes for nuclear maturity and CCM at study initiation and correctly predicted nuclear maturity from CCM in 74, 64, and 47% of oocytes, respectively. Embryologist 1 did not significantly change in predictive ability during the 17-month study period. Embryologist 2 significantly improved in predictive ability during the first 9 months of the study (841 oocytes evaluated) and plateaued thereafter, at a similar percentage of correct predictions as embryologist 1. Embryologist 3 continued to improve in predictive ability throughout the study period, reaching 61% correct predictions at the close of the study after evaluating 223 oocytes. Once embryologists had plateaued in their predictive ability, 72% of oocytes evaluated received the correct nuclear maturity classification based on CCM. Significantly fewer oocytes (54%; 375/690) evaluated by embryologists who had not plateaued in their predictive ability received the correct nuclear maturity classification based on CCM. These results indicate that embryologists' ability to predict oocyte nuclear maturity correctly from CCM continues to change over several months even when pretraining video recordings are used before beginning direct evaluations. After embryologists plateaued in their predictive ability, nuclear maturity still could not be correctly predicted from CCM in 28% of oocytes due to asynchrony between nuclear and CCM maturity. Based upon this, circumstances in which the spreading technique should be used for direct assessment of nuclear maturity as opposed to assessment of CCM only are discussed.


Effects of platelet activating factor on mouse sperm function.

Platelet activating factor (PAF) has been implicated in a variety of reproductive processes. This study was designed to investigate the effect of PAF and the specific PAF receptor antagonist, CV-3988, on capacitation and the acrosome reaction in mouse spermatozoa using an in vitro fertilization (IVF) system. When spermatozoa were preincubated for 30 min in medium containing PAF (10(-7) to 10(-11) M), a significant increase in the fertilization rate with both cumulus-free and zona-free oocytes was observed. In contrast, treatment of the spermatozoa with 10(-5) M CV-3988 caused a significant decrease in both sperm motility and fertilization rates with zona-intact and zona-free oocytes. This suppression was reversed by the addition of PAF. Furthermore, the acrosome reaction was enhanced by PAF treatment of spermatozoa in a dose-dependent manner. This stimulation of the acrosome reaction by PAF required the presence of calcium ions in the medium. While 10(-5) M CV-3988 inhibited the acrosome reaction, the inhibition was also reversed by the addition of PAF. These results suggest that PAF can stimulate not only the capacitation process but also the acrosome reaction, both of which are dependent on extracellular calcium.


Embryo density and medium volume effects on early murine embryo development.

One-cell mouse embryos were used to determine the effects of drop size and number of embryos per drop for optimum development in vitro. Embryos were collected from immature C57BL6 female mice superovulated with pregnant mare serum gonadotropin and human chorionic gonadotropin and mated by CD1 males. Groups of 1, 5, 10, or 20 embryos were cultured in 5-, 10-, 20-, or 40-microliters drops of CZB under silicon oil at 37.5 degrees C in a humidified atmosphere of 5% CO2 and 95% air. Development score for embryos cultured in 10 microliters was higher than that of embryos cultured in 20 or 40 microliters. Embryos cultured in groups of 5, 10, or 20 had higher development scores than embryos cultured singly. The highest development score was obtained by the combination of 5 embryos per 10-microliters drop. The percentage of live embryos in 20 or 40 microliters was lower than that of embryos cultured in 10 microliters. Additionally, the percentage of live embryos cultured singly was lower than that of embryos cultured in groups. Our results suggest that a stimulatory interaction occurs among embryos possibly exerted through the secretion of growth factors. This effect can be diluted if the embryos are cultured in large drops or singly.


Analyses of 95 first-trimester spontaneous abortions by chorionic villus sampling and karyotype.

Our purpose was to determine the incidence of chromosomal aneuploidy in first-trimester pregnancy losses using chorionic villus sampling (CVS). All patients presenting for CVS with no fetal cardiac activity were offered CVS. Cytogenetic results were completed in 95 of 96 cases (99%). Eighty-three percent of the karyotypes were aneuploid. The 16 euploid fetuses had no excess of females. CVS is the most reliable method of determining the karyotype of spontaneously aborted fetuses. The incidence of aneuploidy is much greater than in previous reports that analyzed passed products of conception. CVS should be offered to women who present with first-trimester spontaneous abortions.


The genetic risks of in vitro fertilization techniques: the use of an animal model.

The influence of some technical and biological parameters on the genetic characteristics of embryos derived from in vitro fertilization (IVF) techniques was studied. Using a murine model, we assessed the effect of gamete manipulation, gamete maturation stage, and maternal age on the chromosome complements of first-cleavage embryos. We found a positive correlation between some of these parameters and the incidence of the different chromosome abnormalities studied. Regarding aneuploidy, we observed an influence of maternal age, using both prepubertal and old females. Polyspermy showed a positive correlation with in vitro fertilization, the immaturity and overmaturity of the oocytes employed, and the use of prepubertal females. The appearance of diploid female complements was related to oocyte immaturity and prepubertal females, while diploid male complements were directly related to in vitro fertilization. Premature chromosome condensation (PCC) had a direct relationship with oocyte immaturity and in vitro maturation of the oocyte. Finally, structural abnormalities were associated with the process of sperm aging in vitro.


Quantified ultrastructural study of spermatozoa in unexplained failure of in vitro fertilization.

Failure of in vitro fertilization or very low cleavage rates may occur even though oocyte and semen parameters seem satisfactory. Quantified ultrastructural study of spermatozoa was performed in such cases of failure (n = 6) or low cleavage rate (< 20%; n = 4). Through 1 to 11 retrievals, the number of inseminated oocytes ranged from 14 to 145. The results were compared to those of six fertile men. Quantification was achieved by cataloguing cell defects of the spermatozoon heads and mid-/principal pieces of the flagella. Using the data from each specimen, the percentages of total cellular abnormalities in the head/mid-/principal pieces were established. At the level of the head overall percentages for six groups of defects were determined. The overall percentage of combined head abnormalities, defined as the presence of at least three of these six defects on the same spermatozoon head, was established. Statistical differences among control and patient groups were analyzed by nonparametric Mann-Whitney U test. The percentages of anomalies of the midpiece and of the principal piece were not significantly different between patients and controls. Motility assessed by spermogram was considered "functionally uncompromised." In eight patients the percentage of cell alterations of the head (93-100 vs 77.3 +/- 6.4%) and the percentage of combined anomalies of the head (78.1-100 vs 60.8 +/- 8.5%) were significantly different between patients and controls. In two cases, the percentages established for all head parameters considered were not globally different from those observed in controls. Thus in 8 cases of 10, electron microscopy with quantified analysis supplied valuable evidence about the poor quality of these sperm samples judged as normal under light microscopy and may provide an explanation for their impaired fertilizability.(ABSTRACT TRUNCATED AT 250 WORDS)


Sperm electron microscopy for the evaluation of in vitro fertilization failures.

When performing IVF, the clinician is frequently confronted with the failure of fertilization. When the standard parameters to evaluate the male factor are "within normal limits," the conclusion is often made that the lack of fertilization is most likely due to "poor egg quality." These two cases demonstrate the fallacy of this approach and support a more rigorous evaluation of the male factor. Ultrastructural analysis of sperm is underutilized and, as demonstrated by these two cases, can play an essential role in this evaluation process.


Pick from thousands: a collaborative processing model for coded data entry.

Methods for optimizing coded data entry in clinical systems are a frequent topic of system design. We have developed a new mechanism for this type of data entry that we call "Pick From Thousands" (PFT). It combines several known methods, including menu selection, keyword entry, and initial character matching, but adds a new string matching algorithm. The PFT method is more selective than initial character matching for a given number of keystrokes if entries in the coded list have more than one word. Collaborative processing between a PC workstation and the central HELP system computer is used to optimize ease of maintenance and increase the flexibility and performance of the system.


Collaborative care documentation by exception system.

Development of a workstation-based documentation system supporting collaborative care and nurse charting by exception has been underway for the last two and one-half years at Vanderbilt University Medical Center in Nashville, Tennessee. The Pathways system has undergone two major revisions and is currently implemented on three nursing units. The system supports collaborative care by providing a mechanism for entry and printing of collaborative care pathways and collection of exception data. Paper flowsheets for manual charting are generated based on the patient's collaborative pathway and individual needs. The Pathways system has significantly decreased nursing time and effort for documentation. This paper describes the development, implementation, and impact of the workstation-based documentation system.


Signing out patients for off-hours coverage: comparison of manual and computer-aided methods.

This paper evaluates the communication of information to physicians who provide off-hours coverage to inpatients in two Family Practice residency programs. To describe the importance and accessibility of clinical information used by on-call residents in covering hospital patients, we administered a questionnaire. Then following the use of a new computerized sign-out system in one of the programs, residents filled out the same questionnaire again. Residents felt that a "to do" list and information about the patient's "code status" were the most important data desired from sign-out sheets. However, 69% of residents in both programs felt that provision of this information was normally poor. Nearly all of the residents in Buffalo, using an entirely handwritten sign-out sheet, felt it was in need of improvement. Residents in Pittsburgh, using a summary aided by the hospital's computer print-out, felt this need much less acutely. After implementation of a new computerized sign-out sheet in Buffalo, residents indicated a slightly higher level of satisfaction. The work of data entry and re-entry into the computer was unpopular and inefficient. The present method of transferring information at the end of a work day is not satisfactory for residents. Provision of data summaries from existing hospital information systems is a good first step in improving data transfer. A further study of more comprehensive automated sign-out systems is important, because of the increasing discontinuity of house officer care.


A temporal-abstraction system for patient monitoring.

RESUME is a system that performs temporal abstraction of time-stamped data. RESUME is based on a model of three temporal-abstraction mechanisms: point temporal abstraction (a mechanism for abstracting values of several parameters into a value of another parameter); temporal inference (a mechanism for inferring sound logical conclusions over a single interval or two meeting intervals); and temporal interpolation (a mechanism for bridging nonmeeting temporal intervals). Making explicit the knowledge required for temporal abstraction supports the acquisition of that knowledge.


An extended SQL for temporal data management in clinical decision-support systems.

We are developing a database implementation to support temporal data management for the T-HELPER physician workstation, an advice system for protocol-based care of patients who have HIV disease. To understand the requirements for the temporal database, we have analyzed the types of temporal predicates found in clinical-trial protocols. We extend the standard relational data model in three ways to support these querying requirements. First, we incorporate timestamps into the two-dimensional relational table to store the temporal dimension of both instant- and interval-based data. Second, we develop a set of operations on timepoints and intervals to manipulate timestamped data. Third, we modify the relational query language SQL so that its underlying algebra supports the specified operations on timestamps in relational tables. We show that our temporal extension to SQL meets the temporal data-management needs of protocol-directed decision support.


A framework for the knowledge-based interpretation of laboratory data in intensive care units using deductive database technology.

In co-operation with the Institute of Anaesthesiology of the Ludwig-Maximilians-University in Munich a computer-based system for the analysis and interpretation of renal function, fluid and electrolyte metabolism of critical care patients has been developed. This paper focuses on the requirements and implementation aspects of the knowledge-based interpretation for this particular system. Objective of the proposed approach is, to transform an enormous--and constantly increasing--amount of raw data available in modern intensive care units (ICUs) into relevant, patient-oriented information, which is easy to understand by the medical staff. The essential features of a knowledge-based system at an ICU are outlined. A system is described where these features are realized using deductive database technology as a specification paradigm and extended relational databases as an implementation platform. The integration into the hospital information system is highlighted.


Model-based interpretation of the ECG: a methodology for temporal and spatial reasoning.

A new software architecture for automatic interpretation of the electrocardiogram is presented. Using the hypothesize-and-test paradigm, a semi-quantitative physiological model and production rule-based knowledge are combined to reason about time- and space-varying characteristics of complex heart rhythms. A prototype system implementing the methodology accepts a semi-quantitative description of the onset and morphology of the P waves and QRS complexes that are observed in the body-surface electrocardiogram. A beat-by-beat explanation of the origin and consequences of each wave is produced. The output is in the standard cardiology ladder diagram format. The current prototype can perform the full differential diagnosis of 2:1 atrioventricular (AV) block, and can handle correctly complex rhythms such as AV nodal reentrant tachycardia with either hidden or visible P waves, and varying degrees of AV block.


Hierarchical geometric constraint networks as a representation for spatial structural knowledge.

A representation is proposed for capturing generic spatial knowledge about classes of objects in a structural hierarchy of biology. The basic premise is that spatial properties such as shape and relative relationships can be expressed as networks of interacting constraints. The representation is defined, partial implementations that demonstrate practical utility are described for model based organ and protein structure determination, and research issues are presented that must be solved before the representation can be implemented in its entirety. As these issues are resolved the representation will find increasing utility as the foundation for a spatial knowledge base of structural biology.


PEN&PAD (Geriatrics): a Collaborative Patient Record System for the shared care of the elderly.

The PEN&PAD (Geriatrics) project seeks to develop a Collaborative Patient Record System for the hospital based shared care of the elderly. The goal of the project is to produce a single, integrated information system which is both useful and usable by the different practitioner groups involved in geriatric care. A User Centred Design methodology is proposed which makes users and human issues central to the design and development process. Preliminary results indicate that the specification of a Minimum Basic Data Set as the basis of a shared record system is infeasible and undesirable. An architecture is presented which illustrates how the diversity between the different disciplines may be preserved in a Collaborative Patient Record System.


Use of computer network bulletin board systems by disabled persons.

Computer-based electronic support groups are being used by persons facing physical and emotional challenges. Twenty-six users of disability-related electronic support groups responded to a survey designed to determine computer network use and benefits users gain through their network use. The survey included questions about network use for general communication and support, enhancement of communication ability, attainment of knowledge on specific topics, and employment enhancement. Statistically significant results were obtained concerning the perceived benefits of emotional support and communication in relation to network use. Only a small number (n = 9) reported use of the network for employment purposes. These results demonstrate the feasibility of using networks to provide information, services, assistance, and support for disabled and their care providers.


Computer networks promote caregiving collaboration: the ComputerLink Project.

ComputerLink is a specialized computer network designed to support caregivers of persons with Alzheimer's Disease. ComputerLink delivers information, communication, and decision support, accessed through home terminals. It stands as a unique demonstration of how information technologies support collaboration among family caregivers of persons with Alzheimer's Disease, and between caregivers and professionals. In a randomized field experiment involving 102 AD caregivers, 47 caregivers had access to ComputerLink for 12 months, during which they accessed it 3888 times. Behavioral indicators of use demonstrate that ComputerLink promotes collaboration by providing pathways for communications among caregivers and by facilitating their access to information.


CHESS: a computer-based system for providing information, referrals, decision support and social support to people facing medical and other health-related crises.

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS will improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has developed programs in five specific topic areas: Academic Crisis, Adult Children of Alcoholics, AIDS/HIV Infection, Breast Cancer and Sexual Assault. The lessons learned, and the structures developed, will serve as a model for future implementation of CHESS programs in a broad range of other topic areas. CHESS is designed around three major desired outcomes: 1) improving the emotional health status of users; 2) increasing the cost-effective use of health and human services; and 3) reducing the incidence of risk-taking behaviors that can lead to injury or illness. Pilot-testing and initial analysis of controlled evaluation data has shown that CHESS is extensively used, is useful and easy-to-use, and produces positive emotional outcomes. Further evaluation in continuing.


Preliminary evaluation of learning via the AI/LEARN/Rheumatology interactive videodisc system.

AI/LEARN/Rheumatology is a level three videodisc system to teach clinical observational skills in three important diseases: rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. The AI/LEARN software was developed on an independent authoring system called GALE designed for MS-DOS based computers. The purpose of this paper is to present preliminary data about the efficacy of teaching by the use of an interactive videodisc system as evaluated by examinations centered upon disease-oriented learning objectives and by attitude questionnaires. We tested the efficacy of the AI/LEARN/Rheumatology system using both medical students and residents taking the rheumatology elective. Data collected were on learning, attitudes, and ranking of curricular elements of the rotation. We kept records on the student time and search path through the interactive videodisc system. Control data were collected during 1990, before the AI/LEARN/Rheumatology program was available. Data for the treatment groups were collected during 1991 and 1992, while the trainees used the AI/LEARN/Rheumatology system. The basic difference between the control year and the treatment year curricula was the substitution of AI/LEARN/Rheumatology for three hours of lecture covering the three target diseases. AI/LEARN/Rheumatology was as effective as traditional methods of instruction as measured by scores on a multiple choice test. Student and resident learning was related to the time spent on the system. Students and residents ranked the AI/LEARN/Rheumatology system as the single most helpful learning tool in their 8 week rheumatology block, ranking it above the examination of patients.


Iliad's role in the generalization of learning across a medical domain.

Medical informatics could facilitate more effective analysis and use of clinical knowledge by means of expert systems. To be most effective, such systems should be constructed in a manner which is consistent with physicians' cognitive processes. Our past five years' work with a system called Iliad indicates that it provides effective medical training and education. The current research extends our previous work by using a wider array of training and test cases. We also evaluated whether training on specific cases could generalize to improved testing performance on related cases, which featured similar complaints and pathophysiologic mechanisms, but different final diagnoses. In their junior internal medicine clerkship, students (n = 100) completed 1300 Iliad training cases covering 48 diagnoses. The findings indicated improved problem solving on the specifically trained cases as well as the generalization cases. We discuss a possible training model for expert systems such as Iliad.


Can artificial neural networks provide an "expert's" view of medical students performances on computer based simulations?

Artificial neural networks were trained to recognize the test selection patterns of students' successful solutions to seven immunology computer based simulations. When new student's test selections were presented to the trained neural network, their problem solutions were correctly classified as successful or non-successful > 90% of the time. Examination of the neural networks output weights after each test selection revealed a progressive increase for the relevant problem suggesting that a successful solution was represented by the neural network as the accumulation of relevant tests. Unsuccessful problem solutions revealed two patterns of students performances. The first pattern was characterized by low neural network output weights for all seven problems reflecting extensive searching and lack of recognition of relevant information. In the second pattern, the output weights from the neural network were biased towards one of the remaining six incorrect problems suggesting that the student mis-represented the current problem as an instance of a previous problem.


Visualization of large datasets in intensive care.

At the "Institut für Anaesthesiologie der Ludwig-Maximilians-Universität" in Munich a computer-based system for the analysis and interpretation of renal function and fluid and electrolyte metabolism of critical care patients has been developed. This paper describes requirements and implementation aspects of the presentation of data to the physician. Key issue is, how to transform the enormous--and, as we all know, constantly increasing--amount of plain data available in modern intensive care units (ICUs) into relevant information which can be easily turned into therapeutic actions. These issues have been discussed in literature extensively over many years, but with the upcoming of moderately priced, though powerful graphical UNIX workstations an extended functionality is feasible.


Integrating Radiology and Hospital Information Systems: the advantage of shared data.

Information management is central to modern patient care. Computerization of information management has resulted in both departmental systems which serve information needs in locations such as the Radiology Department and in hospital-wide information systems which seek to integrate management of clinical data from many departments. For each of these systems to achieve the goal of maximizing both the effectiveness of health care workers and the quality of patient care, they need to share the data that they capture. Below we discuss a variety of applications, both currently available and in the realm of research protocols, that depend on a high level of communication between Radiology Information Systems and Hospital Information Systems. These examples suggest the benefits of integrating the medically relevant data collected by all of the computer-based information systems in the hospital setting.


Automated Tumor Registry for Oncology. A VA-DHCP MUMPS application.

The VA Automated Tumor Registry for Oncology, Version 2, is a multifaceted, completely automated user-friendly cancer database. Easy to use modules include: Automatic Casefinding; Suspense Files; Abstracting and Printing; Follow-up; Annual Reports; Statistical Reports; Utility Functions.


Integrated ambulatory care services in oncology.

In today's medical care environment of cost containment and restricted reimbursement, it is important to maximize the use of expensive facility and personnel resources. Concurrently, it is important to provide superior and timely patient services in order to remain competitive in an extremely flexible market. There are many areas in today's larger hospital environments where such ideals can be easily achieved. One of the more obvious areas is the automation of appointment and resource scheduling for ambulatory care services. This article focuses on maximizing the use of available physical and personnel resources in the ambulatory care setting of large and specialty hospitals. The Johns Hopkins Oncology Center's integrated outpatient scheduling and resource management systems are used as examples of what can be achieved. It is hoped that the experiences of the Oncology Center in developing these integrated systems will help others in similar efforts.


An interactive, educational model for insulin dosage and dietary adjustment in type I diabetes mellitus.

Joe Daniels is a 41 year old, 76kg male, insulin-treated diabetic patient who was diagnosed as being diabetic in 1972, at the age of 22. Joe recently found that he was having hypoglycaemic symptoms. Using self-monitoring blood glucose equipment glycaemic levels below 3.0 mmol/l were recorded at least once a week while hyperglycaemic readings (> 16 mmol/l) were observed 2-3 times per week. Joe came into hospital to have his glycaemic control improved as doctors were concerned about the risks of him suffering a serious hypoglycaemic attack. Using some of the data collected by Joe while in hospital we will demonstrate how a computer model of glucose-insulin interaction in type I diabetes can be used interactively to teach diabetic patients about their diabetes and educate them to adjust their own insulin injections and diet.


ROENTGEN: case-based reasoning and radiation therapy planning.

ROENTGEN is a design assistant for radiation therapy planning which uses case-based reasoning, an artificial intelligence technique. It learns both from specific problem-solving experiences and from direct instruction from the user. The first sort of learning is the normal case-based method of storing problem solutions so that they can be reused. The second sort is necessary because ROENTGEN does not, initially, have an internal model of the physics of its problem domain. This dependence on explicit user instruction brings to the forefront representational questions regarding indexing, failure definition, failure explanation and repair. This paper presents the techniques used by ROENTGEN in its knowledge acquisition and design activities.


Designing computer assisted instruction programs for diabetic patients: how can we make them really useful?

Despite the increasing potential of computers for educational use, experience shows that few Computer Assisted Instruction (CAI) programs for patient education have been accepted into routine use by health care providers. A CAI program on hypoglycemia for insulin dependent diabetics, which was developed by the authors and has been widely used in Europe for over 6 years, is described and is used to illustrate some specific difficulties and possible solutions when using computers for patient education. We hope to show that patients suffering from a chronic disease, such as diabetes, require specific skills which are very different in nature from the theoretic knowledge they usually receive from different sources, including health care providers. In order to be really useful, a CAI program for patients must help them to cope with their disease and take into account patients' concerns, fears, and misconceptions as far as possible. Far beyond a detailed knowledge of the domain, a deep experience in patient education is mandatory to understand patients' needs.


The Columbia Registry of Controlled Clinical Computer Trials.

Numerous reports on randomized controlled clinical trials of computer-based interventions have been published. These trials provide useful evaluations of the impact of information technology on patient care. Unfortunately, several obstacles make access to the trial reports difficult. Barriers include the large variety of publications in which reports may appear, non-standard descriptors, and incomplete indexing. Some analyzers indicate inadequate testing of computer methods. The purpose of establishing a registry of randomized controlled clinical computer trials was to assist the identification of computer services with demonstrated ability to improve the process or outcome of patient care. A report collection, selection, information extraction, and registration method was developed and implemented. One hundred and six reports on computer trials have been collected. A large variety of computer-assisted interventions have been tested in the registered trials (40% reminder, 15% feedback, 14% dose planning, 14% patient education, 12% medical record). 76% of the registered reports were published in the United States and most of the remainder in various European countries. In reporting computer trial results, 77% of the authors did not use both the "computer" and "trial" keywords in the title or abstract of their papers. We conclude that a major obstacle to adequate computer technology assessment is inadequate access to the published results.


Automated integration of external databases: a knowledge-based approach to enhancing rule-based expert systems.

Expert system applications in the biomedical domain have long been hampered by the difficulty inherent in maintaining and extending large knowledge bases. We have developed a knowledge-based method for automatically augmenting such knowledge bases. The method consists of automatically integrating data contained in commercially available, external, on-line databases with data contained in an expert system's knowledge base. We have built a prototype system, named DBX, using this technique to augment an expert system's knowledge base as a decision support aid and as a bibliographic retrieval tool. In this paper, we describe this prototype system in detail, illustrate its use and discuss the lessons we have learned in its implementation.


Incorporating knowledge to databases--a solution to complex domains.

This paper describes the design of an integrated environment to handle information on congenital heart disease patients. A three-layer model that integrates a database, a knowledge-base and a graphical user-interface is presented. The role of each layer and its connections is discussed. The advantages of using a hypertext front-end system to present and retrieve complex data are also addressed. The current status of the project and its future developments are described in the final section.


The SQLX system: generating explanations for clinical rules encoded in SQL.

We have developed a system to provide case-specific explanations for SQL query results. The explanation facility, called SQLX, is intended to improve user acceptance of clinical rules that are encoded in the SQL query language and are triggered by updates to a relational database. Our design goal is to combine the efficiency and familiarity of the SQL query model with a more intuitive and case-specific display of query results. SQLX defines an augmented SQL syntax that allows the incorporation of explanation text directly into query specifications. A query analyzer determines which retrieved data logically contribute to rule firing, and combines the data with explanation text to generate a case-specific explanation. Although features of the SQL query model limit the use of this method as a general-purpose rule-explanation facility, the current design accommodates a wide range of SQL query formulations and can provide efficient processing and intuitive explanations of many clinical rules.


Development of a clinical data architecture.

This paper presents a methodology for developing a data architecture for clinical medicine. The methodology uses an object-oriented analysis approach that takes advantage of the domain expertise of practicing physicians. The resulting high-level data model combines a structured, event-based model of clinical information with the process-oriented structures usually associated with problem lists and practice protocols.


Visualization of multimodal image information in medicine.

Radiological and clinical practice can be enhanced by improved access to multimodal image informations. Analysis, visualization, method characteristic image processing and image synthesis is needed not only for the interpretation of the images but also for performing effective consultations with clinical colleagues and computer supported therapy planning and control strategies. The distributed system RADVIS (radiological visualization) is presented which enables the fast display, three dimensional visualization and the modality oriented analysis of multimodal image informations. Based on a unique image format, modality specific evaluation procedures and two- or three dimensional processing tools of image analysis produce the input data for therapy planning programs. The easy use of this multimedia visualisation tool enables radiologists and clinicians to deal with their image data. The description of methods and procedures of the prototype, as well as typical examples of radiologic practice will demonstrate the efficiency of the presented system.


Collaborative development of a uniform graphical interface.

A uniform graphical user interface to informational databases is evolving at the University of Washington through a collaborative development process. The interface, called WILLOW, has grown from model analysis and preliminary design to working prototype. The design replicates a natural flow of search retrieval. Development continues in a spiral of test and linear improvements based on user analysis. WILLOW's internal structure is built on a Unix client-server model communicating over the campus TCP/IP backbone network. Its external structure is an X-Windows/Motif visual presentation emphasizing a simple, consistent, graphical face to disparate information databases. The WILLOW collaborators have grown from an initial group composed of the Health Sciences Library & Information Center and Computing & Communications' Information Systems to the University Libraries, Computing & Communications divisions, Medical Center Information Systems, and departments throughout the health sciences.


The effects of time delays on a telepathology user interface.

Telepathology enables a pathologist to examine physically distant tissue samples by microscope operation over a communication link. Communication links can impose time delays which cause difficulties in controlling the remote device. Such difficulties were found in a microscope teleoperation system. Since the user interface is critical to pathologist's acceptance of telepathology, we redesigned the user interface for this system, built two different versions (a keypad whose movement commands operated by specifying a start command followed by a stop command and a trackball interface whose movement commands were incremental and directly proportional to the rotation of the trackball). We then conducted a pilot study to determine the effect of time delays on the new user interfaces. In our experiment, the keypad was the faster interface when the time delay is short. There was no evidence to favor either the keypad or trackball when the time delay was longer. Inexperienced participants benefitted by allowing them to move long distances over the microscope slide by dragging the field-of-view indicator on the touchscreen control panel. The experiment suggests that changes could be made to the trackball interface which would improve its performance.


PureMD: a Computerized Patient Record software for direct data entry by physicians using a keyboard-free pen-based portable computer.

This paper describes the data acquisition features of the PureMD Computerized Patient Record (CPR) software designed specifically for physicians. The physician uses a stylus to point, draw and handwrite on a Dynamic Dialog Interface that provides the same flexibility as the paper record and numerous other advantages. The clinical data thus entered is highly organized, easily legible and retrievable in many ways. The underlying Medical Knowledge Base (MKB) was optimized for rapid, intuitive and consistent data entry and automatic coding with minimum handwriting.


User-specific interfaces for clinical data-management systems: an object-based approach.

Multiple user-specific visual interfaces are desirable in any computer-based clinical data-management system that is used by different people with different jobs to perform. The programming and maintenance problems of supporting multiple user interfaces to a single information system can be addressed by separating user-interface functionality from data-management subsystems, and by building user interfaces from object-based software components whose functionality is bound to an underlying server-client data-management architecture. Experience with this approach in a patient-tracking system suggests that this object-based approach is viable in the design of a user interface for a clinical information system.


Integrating the UMLS into VNS Retriever.

We are developing a networked resource for the National Library of Medicine's Unified Medical Language System. We call this resource the UMLS Retriever, which is an instance of our VNS Retriever architecture. Our prototype user interface makes use of the Virtual Notebook System Browser. The development of a networked UMLS service will result in numerous advantages to our user community.


Development of a model of information security requirements for enterprise-wide medical information systems.

Information security methods developed within the narrow frameworks of operating system design, specific database models, and military security methods all concentrate on representation of the objects of access control, rather than on the information needs of the subjects. This approach does not adequately support the needs of the varied users of medical information systems, who must have access to information in support of multiple organizational roles. A new conceptual approach to access control in medical settings based on user requirements is discussed.


An evaluation of the source selection elements of the prototype UMLS Information Sources Map.

The Information Sources Map (ISM) is a component of the National Library of Medicine's Unified Medical Language System (UMLS) project. The ISM is intended to provide both human-readable and machine-interpretable information about the content, scope, and access conditions for various information sources such as databases, expert systems, and the organizations which make these information sources available. Automated source selection is supported by three types of indexing in the ISM: Medical Subject Heading (MeSH) terms and subheadings; Semantic Types from the UMLS Semantic Network; and Semantic Type Relations, which depict pairs of semantic types joined by a relationship chosen from the Semantic Network. This paper reports a study of the recall and precision of the source selection elements in the prototype version of the ISM.


The homogenization of the Metathesaurus schema and distribution format.

The third version of the UMLS Metathesaurus, Meta-1.2, to be released in October 1992, will have a simpler schema and simpler distribution formats than the first two versions, Meta-1.0 and Meta-1.1 released in October 1990 and 1991, respectively. For one thing, it will have only a single kind of entry (Concept), rather than three (Concept, Related, and Synonym). Further, the Relational Format, will consist of four logical relations, or tables, instead of the nearly three score different tables used to represent the same kind of information in Meta-1.1. These four tables will contain, respectively, (1) the names of each concept, (2) the relationships between concepts, (3) attributes of the concepts, and (4) a word-based index into the concept names. We argue that the new schema and formats provide a better conceptual model of the Metathesaurus, and represent the information contained there more uniformly. Even though these changes are incremental and evolutionary, both users and software developers should find the Meta-1.2 significantly easier to understand, and the information contained in it significantly easier to use.


Ongoing development of the Critical Care Information System: the collaborative approach to automating information management in an intensive care unit.

Point-of-care (bedside) clinical information systems can fulfill a variety of functions. Included in these functions are: becoming receptacles for patient data and allowing data to be manipulated into formats that facilitate clinical decision making; functioning as sources for billing and auditing processes; interfacing to other hospital systems and bringing distant data to the bedside; and being a repository for information used in the development of hierarchical and/or relational databases. The initial and ongoing development of these systems in a dynamic clinical environment requires the construction of processes and work pathways to ensure that the needs and requirements of myriad personnel, departments and agencies within the health center milieu are addressed.


An integrated multidepartmental hospital imaging system: usage of data across specialties.

Development of automated medical information systems requires knowledge about the utilization of the system; both for design and as feedback during the development process. One of the significant advantages of computer systems is that they can provide an automatic log of system utilization. This paper reports the first study of utilization data collected automatically in an integrated image environment. System monitoring indicates that images are routinely used in clinical care and clinical conferences. Selected images are shown repeatedly for teaching, demonstration, and reference at locations throughout the hospital. Images are viewed both by the collecting service when producing procedure reports and consultations, as well as by the treating physicians from other hospital services. Medical departments have developed image collection policies to meet their internal needs and the needs of treating physicians.


The Meta-1.2 engine: a refined strategy for linking biomedical vocabularies.

This paper presents a preliminary description of the database schema and associated procedures that are the foundation for the "engine" that will produce Meta-1.2. Meta-1.2 is the next incarnation of the Metathesaurus, which is one of the principal components of the National Library of Medicine's Unified Medical Language System (UMLS). We use the word "engine" as a generic term that includes a database and the programs that operate on it. While this design builds heavily upon previous work, it incorporates some major changes in philosophy. A major hypothesis is that the simple representation described here is suitable for any controlled vocabulary in the biomedical domain. Indeed, this hypothesis is central to a strategy for producing future versions of the Metathesaurus and for supporting collaboration with people who wish to contribute additional terms and relationships to the Metathesaurus. Another change involves the representation of classes and relationships. The revised database schema includes an explicit representation of the source or "authority" for relationships, which is analogous to the way that the sources of terms have been represented since the first version of the Metathesaurus. A sequence of steps utilizing the new representations to produce the Metathesaurus is presented.


The UMLS coverage of clinical radiology.

The informational content of clinical radiology reports was examined to determine the coverage of the Unified Medical Language System (UMLS) in relation to the terminology used by physicians in the Radiology Department of Columbia Presbyterian Medical Center (CPMC). The UMLS semantic network contained 17 semantic types which were compatible with the types of clinical information in the reports. The type of semantic categories missing from the UMLS consisted mainly of modifier information relating to certainty, degree, and change type of information. This type of information formed a substantial part of the domain. Although most of the informational categories were found in the UMLS semantic network, most of the domain terms were not. Our results strongly suggest that the UMLS could be a significant tool for developing clinical text processing applications if it were extended to cover clinical domains.


Information seeking by nurses during beginning-of-shift activities.

Information seeking by nurses at the beginning of a work shift is related to planning interventions and other patient activities. Subjects were observed for one hour following morning shift report. The most frequent type of information sought was medication schedules and other information related to medications. On average, nurses spent one-quarter of the first hour after shift report looking for and retrieving information. Nursing information, such as assessments and nursing summaries, required more time to retrieve than other types of information. Findings are compared to earlier research about nurses' information seeking.


GPSYCH: Clinical management software for a Geropsychiatry Division.

We have implemented a clinical management software system for an academic Geropsychiatry Division that allows us to gain many benefits of a computerized medical record system with minimal development and maintenance expense. We use brief electronic records to capture key information, combining coded and free-text formats. Data entry is fast and simple, readily accomplished by physicians during clinical rounds (for inpatients), or by clerk (from outpatient encounter forms). Sufficient clinical data is stored to be useful in patient management, and to support administrative and clinical research functions.


ROUNDS: a customizable HELP results review program for hospital staff physicians.

Physicians rely on the ready availability of clinical data such as laboratory results and procedure reports for the delivery of quality patient care. Such data may be obtained through telephone calls, printed reports or results review programs provided by hospital information systems, but the process is often time-consuming and laborious. To facilitate rapid access to critical patient data, an online M.D. Rounds Report program, ROUNDS, was developed as an adjunct to the HELP System at Rex Hospital. Qualified users may automatically obtain information on allergies and current medications, laboratory results, radiology reports and therapist notes for a list of patients without having to make additional menu or submenu selections. A detailed description of the M.D. Rounds Report program, along with a review of implementation objectives, physician evaluation, usage statistics, and the impact on future physician subsystem development, will be presented.


Patient discharge referral: interdisciplinary collaboration.

The INFORMM (Information Network For Online Retrieval & Medical Management) patient discharge referral form is interdisciplinary in scope. The initial automated form, implemented on 41 general inpatient care units as of December, 1991, involved the collaboration of the departments of Nursing, Social Services, Medical Records, and Patient Registration. As development proceeds, it is expected that other clinical disciplines will contribute additional data and information to augment and complement the content of the patient discharge referral form.


Rule set reduction using augmented decision table and semantic subsumption techniques: application to cholesterol guidelines.

Clinical practice guidelines must comprehensively address all logically possible situations, but this completeness may result in sizable and cumbersome rule sets. We applied rule set reduction techniques to a 576-rule set regarding recommendations for medication treatment of hypercholesterolemia. Using decision tables augmented with information regarding test costs and rule application frequencies, we sorted the rule sets prior to identifying irrelevant tests and eliminating unnecessary rules. Alternatively, we examined the semantic relationships among risk factors in hypercholesterolemia and applied a subsumption technique to reduce the rule set. Both methodologies resulted in substantial rule set compression (mean, 48-70%). Subsumption techniques proved superior for compacting a large rule set based on risk factors.


Computer assisted development of diagnostic expert systems. A domain-independent package (EMPTY) for acquisition and use of expert's medical knowledge.

The package EMPTY has been developed with the aim of providing a tool based on well assessed methodological principles which can support both the organisation and use of medical knowledge for diagnostic and educational purposes. EMPTY is domain-independent and results in two interactive programs: ASK guides the acquisition of medical knowledge and RUN supports medical decision-making and provides facilities for medical education. The knowledge bases developed on ASK have a standard formal structure: they include taxonomies, definitions and descriptions of diseases, clinical findings and investigations; production rules for activation and refinement of diagnostic hypotheses; frame-like profiles of diseases; and quantitative criteria for scoring the clinical evidence on the base of available data.


Graph-grammar productions for the modeling of medical dilemmas.

We introduce graph-grammar production rules, which can guide physicians to construct models for normative decision making. A physician describes a medical decision problem using standard terminology, and the graph-grammar system matches a graph-manipulation rule to each of the standard terms. With minimal help from the physician, these graph-manipulation rules can construct an appropriate Bayesian probabilistic network. The physician can then assess the necessary probabilities and utilities to arrive at a rational decision. The grammar relies on prototypical forms that we have observed in models of medical dilemmas. We have found graph grammars to be a concise and expressive formalism for describing prototypical forms, and we believe such grammars can greatly facilitate the modeling of medical dilemmas and medical plans.


Electronic imaging of the human body.

The Human Engineering Division of the Armstrong Laboratory (USAF); the Mallinckrodt Institute of Radiology; the Washington University School of Medicine; and the Lister-Hill National Center for Biomedical Communication, National Library of Medicine are sponsoring a working group on electronic imaging of the human body. Electronic imaging of the surface of the human body has been pursued and developed by a number of disciplines including radiology, forensics, surgery, engineering, medical education, and anthropometry. The applications range from reconstructive surgery to computer-aided design (CAD) of protective equipment. Although these areas appear unrelated, they have a great deal of commonality. All the organizations working in this area are faced with the challenges of collecting, reducing, and formatting the data in an efficient and standard manner; storing this data in a computerized database to make it readily accessible; and developing software applications that can visualize, manipulate, and analyze the data. This working group is being established to encourage effective use of the resources of all the various groups and disciplines involved in electronic imaging of the human body surface by providing a forum for discussing progress and challenges with these types of data.


Representation of clinical data using SNOMED III and conceptual graphs.

None of the coding schemes currently contained within the Unified Medical Language System (UMLS) is sufficiently expressive to represent medical progress notes adequately. Some coding schemes suffer from domain incompleteness, others suffer from the inability to represent modifiers and time references, and some suffer from both problems. The recently released version of the Systematized Nomenclature of Medicine (SNOMED III) is a potential solution to the data-representation problem because it is relatively domain complete, and because it uses a generative coding scheme that will allow the construction of codes that contain modifiers and time references. SNOMED III does have an important weakness, however. SNOMED III lacks a formalized system for using its codes; thus, it fails to ensure consistency in its use across different institutions. Application of conceptual-graph formalisms to SNOMED III can ensure such consistency of use. Conceptual-graph formalisms will also allow mapping of the resulting SNOMED III codes onto relational data models and onto other formal systems, such as first-order predicate calculus.


PFGE MAPPER and PFGE READER: two tools to aid in the analysis and data input of pulse field gel electrophoresis maps.

Pulse field gel electrophoresis mapping is an important technique for characterizing large segments of DNA. We have developed two tools to aid in the construction of pulse field electrophoresis gel maps: PFGE READER which stores experimental conditions and calculates fragment sizes and PFGE MAPPER which constructs pulse field gel electrophoresis maps.


CHROMINFO: a database for viewing and editing top-level chromosome data.

CHROMINFO is a prototype database that is intended to serve as a liaison tool for researchers working in different centers on mapping of the same mammalian chromosome. It provides a bird's-eye-view of top-level entities on a chromosome (such as gene loci, chromosome breakpoints and contigs) and relates them to one another in one dimension, the axis of the chromosome. Consensus data can be entered, edited, queried and displayed in a variety of ways. Summary evidence for consensus data can also be stored and retrieved. Information may be downloaded from the Genome Data Base periodically, and order and distance information is then incorporated. The prototype of CHROMINFO was built for human chromosome 16. Versions have been created for several other chromosomes.


The SENEX Project: knowledge representation in molecular pathology.

SENEX is a computer program for students, educators, and research investigators in the domain of molecular pathology. The application allows an individual to ask a sequence of questions in a single interactive session, thereby facilitating the development and testing of several hypotheses in a short period of time. Graphical representations of molecules and molecular events help enable individuals to grasp spatial and functional relationships (and in the future, temporal relationships) among molecules, cellular compartments, and cell regions. Fairly simple but well-defined reasoning capabilities allow an individual to ask sophisticated questions and to predict novel molecular events or pathways. SENEX contains information about: 1) molecules and the motifs that impart function to these molecules; 2) molecular events; 3) cell-specific expression of genes; 4) disease processes. SENEX is being developed through object-oriented programming in a portable programming environment supported by COMMON LISP and the COMMON LISP INTERFACE MANAGER.


A method for publishing genomic maps.

We describe a method for the creation, manipulation and publication of physical human genome maps. Employing an "intelligent" document interface metaphor, our system uses a commercially available programmable document production system as an interface to primary genetic data resources and externally created mapping algorithms. Our document architecture distinguishes between primary data (usually obtained through database queries) and both manual and programmatic manipulations on these data. Our document architecture can be extended to accommodate a wide range of genetic and physical mapping problems. Because our approach is based on a widely available document preparation product, the principal focus of activity remains centered on the production of genomic maps that can be made available in a wide range of paper and electronic formats.


The findings--diagnosis continuum: implications for image descriptions and clinical databases.

As part of the Unified Medical Language System (UMLS) project, we have been exploring the use of semantic net representation to build a medical ontology that can adapt to the needs and perspective of differing kinds of users with varying purposes. A principal objective is to facilitate indexing and retrieval of objects in a variety of target databases, using their own source vocabularies, while maintaining the representation of concepts to which these source vocabularies refer in a single consistent form, so that retrievals that span resource types can be accommodated. In addition, a particular area of deficiency of the existing UMLS Metathesaurus is that of clinical findings, a part of the problem being the multiple alternative views and granularity levels at which clinical findings are described in different target databases. The problem is particularly obvious when one examines the way in which image findings are described, which may be at a purely perceptual level, or at varying levels of aggregation into higher level observations or interpretations. We have developed a recursive model for representing observations and interpretations in a semantic net along a continuum of degree of aggregation, that appears to lend itself well to adaptation to varying perspectives.


Enhancing the Metathesaurus with clinically relevant concepts: anatomic representations.

To create a comprehensive taxonomy for medical concepts it is necessary to identify gaps and reconcile differences that exist between clinical, bibliographic, and other source vocabularies. As part of the Unified Medical Language System project, we have proposed enhancements to the Metathesaurus by the inclusion of terms from two source vocabularies with different unique perspectives or views. This process has disclosed a number of issues that arise as complexity increases. These issues must be resolved if the resultant Metathesaurus is to support the variety of uses for which it is intended.


Representation of nursing terminology in the UMLS Metathesaurus: a pilot study.

To see whether the National Library of Medicine's Metathesaurus (tm) includes terminology relevant to clinical nursing practice, two widely used nursing vocabularies were matched against the Meta. The two nursing vocabularies are 1) the North American Nursing Diagnosis List of Approved Diagnoses; and 2) the Omaha System, a vocabulary of problems and interventions developed by the Omaha Visiting Nurses Association. First, the terms were scanned against Meta in their "native" form, with phrases and combinations intact. This produced a relatively low percentage of exact matches (12%). Next, the terms were separated into "core concepts" and "modifiers" and the analysis was repeated. The percentage of exact matches to terms in Meta increased to 32%. However, the semantic types of the split terms often were not equivalent to the semantic types of the phrases from which the split terms were derived; also, in some cases, terms returned as exact matches had different meanings in Meta. Automatic scanning for lexical matches is a helpful first step in searching for vocabulary representation in Meta, but term-by-term search for context, semantic type and definition is essential. However, it seems clear that representation of nursing terminology in the Metathesaurus needs to be expanded.


The clinical utility of META: an analysis for hypertension.

To evaluate the clinical completeness of the National Library of Medicine Metathesaurus(META), we coded the conceptual information found in 2000 problem oriented (SOAP) notes for hypertension from one COSTAR site. To minimize the effects of practice idiosyncracy, we analyzed an additional 500 notes from a second, geographically remote site. Concepts occurring at either site numbered 1337. We classified concepts occurring at both sites as core concepts and these numbered 121. We attempted to find a matching concept of the proper semantic type in META for each of the items. All matching was done by program with a manual review by a physician. The overall success rate for matching was: [table: see text] We observed the greatest frequency of unmatched concepts in physical examination, medications, symptoms, personal behavior, non-medical therapies and counselling. We conclude that the current release of META is not sufficiently rich to describe the process of care in the ambulatory management of hypertension. However, the construction and breadth of the current scheme holds promise for medical knowledge representation and translation.


A bidirectional ACR-NEMA interface between the VA's DHCP Integrated Imaging System and the Siemens-Loral PACS.

There is a wide range of requirements for digital hospital imaging systems. Radiology needs very high resolution black and white images. Other diagnostic disciplines need high resolution color imaging capabilities. Images need to be displayed in many locations throughout the hospital. Different imaging systems within a hospital need to cooperate in order to show the whole picture. At the Baltimore VA Medical Center, the DHCP Integrated Imaging System and a commercial Picture Archiving and Communication System (PACS) work in concert to provide a wide-range of departmental and hospital-wide imaging capabilities. An interface between the DHCP and the Siemens-Loral PACS systems enables patient text and image data to be passed between the two systems. The interface uses ACR-NEMA 2.0 Standard messages extended with shadow groups based on draft ACR-NEMA 3.0 prototypes. A Novell file server, accessible to both systems via Ethernet, is used to communicate all the messages. Patient identification information, orders, ADT, procedure status, changes, patient reports, and images are sent between the two systems across the interface. The systems together provide an extensive set of imaging capabilities for both the specialist and the general practitioner.


Expert nurses' clinical reasoning under uncertainty: representation, structure, and process.

How do expert nurses reason when planning care and making clinical decisions for a patient who is at risk, and whose outcome is uncertain? In this study, a case study involving a critically ill elderly woman whose condition deteriorated over time, was presented in segments to ten expert critical care nurses. Think aloud method was used to elicit knowledge from these experts to provide conceptual information about their knowledge and to reveal their reasoning processes and problem-solving strategies. The verbatim transcripts were then analyzed using a systematic three-step method that makes analysis easier and adds creditability to study findings by providing a means of retracing and explaining analysis results. Findings revealed information about how patient problems were represented during reasoning, the manner in which experts subjects structured their plan of care, and the reasoning processes and heuristics they used to formulate solutions for resolving the patient's problems and preventing deterioration in the patient's condition.


Collaboration in task analysis for developing a database to record the essential clinical behaviors of nursing students.

This database for recording the Essential Clinical Behaviors of nursing students is the result of collaboration between nursing faculty and an instructional designer at Ball State University in Muncie, Indiana. The database was developed to aid nursing instructors in recording and tracking those student behaviors and skills essential to nursing education. The developers of the database are continuing to work toward the goal of having students record data and prepare reports. This would enable the students to be more self-directed in seeking appropriate and essential clinical experiences.


Curriculum planning and computer-assisted instruction (CAI) within clinical nursing education.

Some experts in nursing and computers have stated that the integration of the computer within nursing education needs to be planned. It has also been declared that there is a need for a body of knowledge that describes the planning and implementing of CAI and the degree of success with the implementation of CAI within nursing education. There is a paucity of literature addressing the planning, implementing, and evaluation of CAI within clinical nursing education. The purpose of this paper is to add to a knowledge base for the successful implementation of CAI within clinical nursing education. The information in this paper is based upon a two year study of CAI use within the clinical component of one course within a baccalaureate nursing program. A description of this approach to clinical nursing education is provided.


Supporting collaboration through a nursing informatics curriculum stage II.

Collaboration is at the center of the process used to design, implement and evaluate an integrated informatics curriculum in a baccalaureate nursing program. This paper describes the second stage of a process to design the informatics nursing courses. The challenges to foster faculty collaborative relationships as well as to enhance the course content of all nursing informatics curriculum. A number of strategies were used to develop the collaborative efforts between the faculty and nursing staff in the clinical agencies. Information technology was incorporated into the didactic and clinical portions of courses through the use of creative teaching strategies. Therefore, the faculty have ensured a blend of information, technology, and the clinical care process throughout the curriculum.


Integration of a stand-alone expert system with a hospital information system.

A stand-alone PC expert system for evaluating the appropriateness of inpatient admissions has been integrated with an existing hospital information system. The expert system supports preadmission screening for appropriateness of inpatient admissions. The HIS provides extensive clinical data in a coded electronic form, permitting high-level decision support. The integrated system was developed for a 20 week randomized clinical trial to evaluate the effects of preadmission screening on inappropriate inpatient admissions. Three factors of the integration are considered: programmatic integration of the expert system, seamless presentation of mixed platform applications, and integration of coded data from the stand-alone application into the HIS data structure.


The design of a rule-based clinical event monitor in a multi-vendor hospital computing environment.

The Clinical Event Monitor (CEM) described here is a prototype system designed to explore the issues involved in building an institutional CEM that permits rapid, automated evaluation of clinical transactions and notification to clinicians of exceptional events in a multi-vendor computing environment. The CEM uses expert systems, database, and systems integration techniques. Ancillary (departmental) applications, including as Patient Registration, Laboratories, and Pharmacy have been licensed from commercial vendors. Application-to-application and application-to-database interfaces were built to mirror subsets of the ancillary patient databases into an institutional relational database (Oracle). The CEM receives registration updates via an HL7 message and evaluates data dependencies in rules via an interface to the relational database. The CEM engine was built using Nexpert, a commercially available expert system shell. Our short term goals were to: (1) build and maintain a patient census within the expert system environment via net based HL7 update broadcasts; (2) explore the data-driven features of Nexpert, (3) deliver prototype exception reports. This paper describes in general terms the design features of the CEM and in detail the features of a patient registry to NEXPERT bridge (from Oracle via HL7 structured transactions to NEXPERT) and the delivery of exception reports.


Prevention of adverse drug events through computerized surveillance.

Adverse drug events (ADEs) are a serious health problem and are the leading adverse event experienced by hospitalized patients. Numerous hospitals have used different methods to improve the reporting of ADEs but few have undertaken studies aimed at the prevention of ADEs. We found that computerized ADE surveillance identified significantly more ADEs than our previous voluntary reporting method. Moreover, the computerized ADE surveillance system created a database of ADEs which allowed us to analyze the ADEs and design methods for prevention. We found that computer alerts of previously known drug allergies generated when drugs were ordered significantly reduced the number of type B ADEs, 56 vs 8 (p < 0.001). In addition, we found that the timely surveillance of ADEs combined with physician notification reduced the number of severe ADEs, 41 vs 12 (p < 0.001). Initial analysis of the ADE database has shown that on average patients with type B ADEs are hospitalized longer (17 vs 14 days) and have larger hospitalization costs ($30,617 vs $23,256) than patients with type A ADEs. Patients with severe ADEs also are hospitalized longer (20 vs 13 days) and have larger hospitalization costs ($38,007 vs $22,474) than patients with moderate ADEs. This indicates that the prevention and early treatment of ADEs can reduce the length of hospitalization and result in a considerable cost savings to the hospital.


Formalized decision-support for cardiovascular intensive care.

The massive volume of hemodynamic data routinely available within the Cardiovascular Intensive Care Unit (CVICU) can adversely affect the quality, relevance and timing of hemodynamic management decisions on patients after cardiac surgery. Yet, at the same time, the lack of appropriate treatment-outcome data and access to prior CV case histories deprives the clinician of any opportunity to improve personal decision-making skill and assess the effectiveness of various treatment methods. This paper presents a formalized decision-support model for CVICU that incorporates expert and quantitative knowledge, as well as prior outcome and case experience to augment the clinician's decision-making capability. This includes the proposed use of optimal hemodynamic patterns derived from outcome analysis as therapy goals, expert rules and trend analysis to interpret incoming data, standardized protocols based on predefined hemodynamic patterns from clinical cases, and access to the database for similar case comparison. Most importantly, the model suggests an integrated approach where the clinical database is not only a documentation source for the patient, but can also serve as an outcome research database where clinical experience can be formalized and combined with expert knowledge to influence future therapy decisions. At present, a prototype is being developed at the CVICU of the University of Alberta Hospitals on a Unix platform using ART-IM, C and Ingres. Once implemented, the prototype will be evaluated on a small group of CV patients for its effectiveness and acceptability to clinicians.