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Background How medicaldecisions are made in real-life situations is largely unexplored. We explored patients’ perceptions of decision-making during a hospitalization and examined the conformity of the decision process with expert recommendations. Objective To describe the conformity of the decision-making process with current expert opinion and examine the associations between various aspects of the decision-making process and a global assessment of the decision. Methods Mail survey of patients discharged from a teaching hospital in Geneva, Switzerland. Patients identified the main medicaldecision during their stay, and rated the decision process (11-item “decision process score”) and their satisfaction with the decision (five-item “decision satisfaction score”). Both scores were scaled between 0 (worst) and 100 (best). Participants The survey had 1467 respondents. Main Results In total 862 (58.8%) of 1467 respondents reported having made a medicaldecision while in the hospital. The decision process score (mean 78.5, SD 21.5) and the decision satisfaction score (mean 86.5, SD 20.4) were moderately correlated (?=?0.62). Men, healthier patients, patients discharged from the department of surgery, and those who reported sharing the decision with their doctor gave the highest ratings on both scales. Five process variables were independently associated with high satisfaction with the decision: the doctor explained all possible treatments and examinations, the patient was aware of risks at the time of the decision, the doctor’s explanations were easy to understand, the patient was involved in the decision as much as desired or more, and the patient was not pressured into the decision. Conclusions A majority of patients discharged from a general hospital were able to identify and rate a medicaldecision. Recommended features of the process of medicaldecision-making were associated with greater satisfaction with the decision.
Mathematics achievement is important in its own right, and is increasingly recognized as crucial to the nation's economy [National Mathematics Panel, 2006. "National Mathematics Advisory Panel: Strengthening Math Education Through Research." Accessed September 29, 2006 from http://www.ed.gov/about/bdscomm/list/mathpanel/factsheet.html.; National…
Medicaldecision making is sometimes viewed as a relatively simple process in which a decision may be made by the patient, by the physician, or by both patient and physician working together. This two-dimensional portrayal eclipses the important role that others, such as other professionals, family, and friends, may play in the process; as an example of this phenomenon, we trace the evolution of a decision of a teenager with cancer who is contemplating discontinuing chemotherapy. This example also shows how a decision can usefully be understood as consisting of a number of identifiable substeps--what we call the "microstructure" of the decision. These steps show how the physician can play an important role without usurping the patient's rightful decisional authority. PMID:19209569
|Objective: Several conspiring factors have resulted in an increase in the level of medical burden in psychiatric patients. Psychiatry residents require increasing levels of medical sophistication. To assess the medicaldecision-making of psychiatry residents, the authors examined the outcome in subjects initially seen in the emergency psychiatric…
El-Mallakh, Rif; Zinner, Jill; Mackey, Amanda; Tamas, Rebecca L.; Martin, Chanley M.; Dalton, Jerad; Dhaliwal, Nitu; Luddington, Nicole; Numan, Farhad U.; Nunes, Ross; Taylor, Stephen; Ye, Lu
Clinical engineering departments in hospitals are responsible for establishing and regulating a Medical Equipment Management Program to ensure that medical devices are safe and reliable. In order to mitigate functional failures, significant and critical devices should be identified and prioritized. In this paper, we present a multi-criteria decision-making model to prioritize medical devices according to their criticality. Devices with lower
Clinical engineering departments in hospitals are responsible for establishing and regulating a Medical Equipment Management Program to ensure that medical devices are safe and reliable. In order to mitigate functional failures, significant and critical devices should be identified and prioritized. In this paper, we present a multi-criteria decision-making model to prioritize medical devices according to their criticality. Devices with lower
OBJECTIVE: We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically ill or malformed neonates. DESIGN: Data were obtained by questionnaires divided into three sections: 1. sociodemographic; 2. Theoretical principles which might be utilised in the decision-making process; 3. Hypothetical case scenarios, each followed by possible treatment options. RESULTS: Pregnant women (n = 545) consistently requested less aggressive medical intervention for the hypothetical cases than did new mothers (n = 250) [Trisomy 18: 57% v 42%; p = 0.0004; Asphyxia: 75% v 63%; p = 0.0017; Down's syndrome 81% v 62%; p = 0.0001; LBW 85% v 75%; p = 0.004]. Significant differences were also observed in the responses to the theoretical principles, with pregnant women attributing less importance to preserving life at all cost, while being more concerned with physical and emotional pain and suffering, with financial cost, and with the infant's potential for future productivity.
Hammerman, C; Lavie, O; Kornbluth, E; Rabinson, J; Schimmel, M S; Eidelman, A I
An overview is presented of different constraints in conventional medicaldecision-making for improving collaborative reasoning. When designing and implementing an effective assisted diagnoses system it is imperative to make a complete study of reasoning processes used by physicians every day. We are particularly interested in studying the process of conventional decision-making when, at the first stage, a physician faces a
J. M. Quintero; Antonio Aguilera; M. Abraham; H. Villegas; G. Montilla; Basel Solaiman
Two examples of statistical decision as applied to medical diagnosis are presented. The first one concerns the diagnosis of hypertension, i.e. essential hypertension and five types of secondary hypertension: fibrodysplasic renal artery stenosis, atheromatous renal artery stenosis, Conn's syndrome, renal cystic disease and pheochromocytoma. The second deals with the diagnosis of multiple sclerosis by visual, somatosensory and brain stem auditory
A. Blinowska; G. Chatellier; J. Verroust; J. Bernier
This paper presents a tutorial introduction to the handling of uncertainty and decision-making in medical reasoning systems. It focuses on the central role of uncertainty in all of medicine and identifies the major themes that arise in re- search papers. It then reviews simple Bayesian formulations of the problem and pursues their generalization to the Bayesian network methods that are
Objectives: This paper aims to study whether the application of a Group Decision Support System to medical collective decision committees is possible and to determine which GDSS specifications are convenient. Backgrounds: we introduce the common knowledge about GDSS and define the process of the collective medicaldecision. Methods: An experimental GDSS has been tested in an actual medical collective decision
... use only. Living wills and advance directives for medicaldecisions By Mayo Clinic staff Original Article: http:// ... Sign up Living wills and advance directives for medicaldecisions Living wills and other advance directives describe ...
Uncertainty in environmental decision making should not be thought of as a problem that is best ignored. In fact, as is illustrated\\u000a in a simple example, we often informally make use of awareness of uncertainty by hedging decisions away from large losses.\\u000a This hedging can be made explicit and formalized using the methods of decision analysis. While scientific uncertainty is
Current models of care emphasize the importance of including patients’ values in the decision making process. This is particularly important for decisions for which there are few data supporting a clear strategy or treatment choice. Constructing preferences for complex decisions requires that patients be able to consider multiple trade-offs between specific risks and benefits. Several marketing research techniques have been recently applied to heath care settings to facilitate this process. Most can be programmed to generate patients’ preferences or priorities, which can then be used to improve patient-physician communication. In this paper, we will describe some of the currently available approaches that have been successfully used in the healthcare setting. We provide case examples to illustrate the potential value of adopting each of these approaches in clinical practice.
Current models of care emphasize the importance of including patients' values in the decision-making process. This is particularly important for decisions for which there are few data supporting a clear strategy or treatment choice. Constructing preferences for complex decisions requires that patients be able to consider multiple trade-offs between specific risks and benefits. Several marketing research techniques have been recently applied to heath care settings to facilitate this process. Most can be programmed to generate patients' preferences or priorities, which can then be used to improve patient-physician communication. In this article, we will describe some of the currently available approaches that have been successfully used in the health care setting. We provide case examples to illustrate the potential value of adopting each of these approaches in clinical practice. PMID:23132890
The manual covers the range of basic regulatory requirements that all manufacturers must consider when they begin to import a medical device. The materials it contains are useful for guidance and reference on establishment registration, device listing, la...
Medicaldecision support systems can provide assistance in crucial clinical judgments, particularly for inexperienced medical professionals. Fuzzy cognitive maps (FCMs) is a soft computing technique for modeling complex systems, which follows an approach similar to human reasoning and the human decision-making process. FCMs can successfully represent knowledge and human experience, introducing concepts to represent the essential elements and the cause
Chrysostomos D. Stylios; Voula C. Georgopoulos; Georgia A. Malandraki; Spyridoula Chouliara
|Objectives: The purpose of this study was to develop a working model to explain medical specialty decision-making. Using Social Cognitive Career Theory, we examined personality, medical specialty preferences, job satisfaction, and expectations about specialty choice to create a conceptual framework to guide specialty choice decision-making.…
Advances in medical knowledge and technology have created new opportunities for disease specific diagnosis and treatment. The increase in and complexity of medical data at various levels of resolution has increased the need for system level advancements i...
The model selection strategy is an important determinant of the performance and acceptance of a medical diagnostic decision support system based on supervised learning algorithms. This research investigates the potential of various selection strategies from a population of 24 classification models to form ensembles in order to increase the accuracy of decision support systems for the early detection and diagnosis
David West; Paul Mangiameli; Rohit Rampal; Vivian West
This paper presents an analysis of the schools of medicaldecision making (MDM) from a group decision support system (GDSS) viewpoint. This analysis is part of on-going research which focusses on the development of a GDSS framework for MDM, with medical reasoning, problem-solving and collaborative communication features. Medical reasoning and problem-solving are influenced by the choice of a formal method
This research explored the decision-making process of selecting medicines for prescription on hospital ward-rounds. We aimed to determine when and with whom medications were discussed, and in particular, whether shared decision making (SDM) occurred on ward-rounds. As a low level of computerized decision support was in place in the hospital at the time, we also examined whether the decision support aided in any medication discussions. Fourteen specialty teams (46 doctors) were shadowed by the investigator while on ward-rounds and all verbal communication about medications was noted. Most medication discussions took place away from the patient bedside and the majority took place between two or more doctors. While a great deal of doctor-patient communication regarding medications took place on ward-rounds, very little of this comprised SDM. More frequently, doctors informed patients of the medications they would be or were currently taking. The computerized decision support had little impact on treatment decision-making. While the value of SDM is often acknowledged in the literature, it appears to be rarely practiced on hospital ward-rounds. PMID:21893883
Baysari, Melissa; Westbrook, Johanna; Day, Richard
The conference was organized in part to dispel some of the misinformation that interferes with cooperative efforts of attorneys and physicians to redress the malpractice situation. During discussion of the hypothetical case, participants identified how medicaldecision-making responsibilities were allocated among health care providers caring for the patient. Panel members suggested ways in which medicaldecision making might be affected by non-medical factors such as third-party reimbursement (e.g., selection of inpatient or outpatient setting, the opportunity to discuss issues related to informed consent prior to the day of a procedure) and potential malpractice litigation (e.g., documentation in charts, use of diagnostic procedures). The characterization of decision-making roles and responsibilities differed somewhat for purposes of malpractice litigation; that is, which caregivers might be named as defendants. Panel members reconstructed the development of the medical incident into a legal case. Plaintiff's attorney commented that it is often a hospital employee who advises the family to consult an attorney and described some of the constraints on information gathering (e.g., the rule of "discovery" requiring that suit be filed before defendants can be forced to give statements about what happened, insurance contract provisions prohibiting physicians from talking without legal counsel present to persons who indicate that they plan to file suit). He also briefly explained the rationale for the contingency fee arrangement in these cases. Describing the role of the medical expert witness and the need to review the medical record, he outlined the process of deciding whether to pursue a malpractice case. In making this decision, plaintiff's attorney evaluates the facts to identify issues in the case, to determine if there are deviations from the standard of care, and to try to predict jury reaction. If a suit is filed, defense attorneys employed by the hospital, insurance company, or individual defendants will decide, based on facts including coverage limits, possible publicity, and likelihood of successful prosecution, whether the case should be settled and for what amount. Interests represented by the defense attorneys differ and may affect settlement strategies. Physician feelings of concern for the patient/family or desire for vindication will, to varying degrees, be factors in the decision to try or settle a case. Panel members explored several important policy issues. Among these were the effect of malpractice cases on doctor-patient communications and ethical issues concerning expert witnesses.(ABSTRACT TRUNCATED AT 400 WORDS) PMID:2728499
The conference was organized in part to dispel some of the misinformation that interferes with cooperative efforts of attorneys and physicians to redress the malpractice situation. During discussion of the hypothetical case, participants identified how medicaldecision-making responsibilities were allocated among health care providers caring for the patient. Panel members suggested ways in which medicaldecision making might be affected by non-medical factors such as third-party reimbursement (e.g., selection of inpatient or outpatient setting, the opportunity to discuss issues related to informed consent prior to the day of a procedure) and potential malpractice litigation (e.g., documentation in charts, use of diagnostic procedures). The characterization of decision-making roles and responsibilities differed somewhat for purposes of malpractice litigation; that is, which caregivers might be named as defendants. Panel members reconstructed the development of the medical incident into a legal case. Plaintiff's attorney commented that it is often a hospital employee who advises the family to consult an attorney and described some of the constraints on information gathering (e.g., the rule of "discovery" requiring that suit be filed before defendants can be forced to give statements about what happened, insurance contract provisions prohibiting physicians from talking without legal counsel present to persons who indicate that they plan to file suit). He also briefly explained the rationale for the contingency fee arrangement in these cases. Describing the role of the medical expert witness and the need to review the medical record, he outlined the process of deciding whether to pursue a malpractice case. In making this decision, plaintiff's attorney evaluates the facts to identify issues in the case, to determine if there are deviations from the standard of care, and to try to predict jury reaction. If a suit is filed, defense attorneys employed by the hospital, insurance company, or individual defendants will decide, based on facts including coverage limits, possible publicity, and likelihood of successful prosecution, whether the case should be settled and for what amount. Interests represented by the defense attorneys differ and may affect settlement strategies. Physician feelings of concern for the patient/family or desire for vindication will, to varying degrees, be factors in the decision to try or settle a case. Panel members explored several important policy issues. Among these were the effect of malpractice cases on doctor-patient communications and ethical issues concerning expert witnesses.(ABSTRACT TRUNCATED AT 400 WORDS)
There is much discussion on medical ethics literature regarding the importance of the patients' right for self-determination. We discuss some of the limitations of patient's autonomy with the aim to draw attention to the ethical complexity of medicaldecision making in the everyday clinical practice.
The precautionary principle is a useful strategy for decision-making when physicians and patients lack evidence relating to the potential outcomes associated with various choices. According to a version of the principle defended here, one should take reasonable measures to avoid threats that are serious and plausible. The reasonableness of a response to a threat depends on several factors, including benefit vs. harm, realism, proportionality, and consistency. Since a concept of reasonableness plays an essential role in applying the precautionary principle, this principle gives physicians and patients a decision-making strategy that encourages the careful weighing and balancing of different values that one finds in humanistic approaches to clinical reasoning. Properly understood, the principle presents a worthwhile alternative to approaches to clinical reasoning that apply expected utility theory to decision problems. PMID:15512973
... medical problem. The problem was narrowing of the carotid artery. This artery supplies blood to the brain. ... the people in the study actually had narrowed carotid arteries. They were separated into groups. The groups ...
Guideline development, implementation, utility and adherence require intelligence and multimedia to interact in decision support\\u000a environments. However, efforts to combine all these aspects and to connect solutions into a effective, efficient and productive\\u000a environment are rare. In this paper we use a regional health care perspective on maintenance and analysis of data, information\\u000a and knowledge. Examples are drawn from cardiac
Patrik Eklund; Johan Karlsson; Jan Rauch; Milan Simunek
The systematic evolution of a hypermedia-based group decision support system (GDSS) architecture to support collaborative medicaldecision-making (MDM) is presented in this paper. This GDSS is for subsequent use by designers and researchers in the GDSS\\/medical informatics arena who can use several or parts of the presented architecture for effecting collaborative MDM. The GDSS design also supports various levels of
A simplified method for the rapid identification of medicallyimportant fungi is presented in the form of a dichotomous key. By noting the presence or absence of diagnostic features, one can effectively use the key to separate medicallyimportant fungi from other fungi. An unfamiliar fungus of medicalimportance in tissue or culture can be identified to genus within minutes
Taking decisions in the medical domain is a very complex task. The context is strongly affected by uncertainty and the possible undesired side effects of the treatments have to be carefully considered. Currently, these decisions are based on the physician's own experience and the evidences of the published literature, according, when available, with the philosophy of Evidence Based Medicine. The main issues of this approach are that the own experience can be different, and the results in the literature are sometimes contrasting. For helping physicians while taking medicaldecisions, we are proposing an innovative approach based on the idea of the clinical similarity. Given a set of clinical variables, the proposed approach selects patients that are similar, presenting to the physician the respective decisions taken and the corresponding clinical effects. PMID:23920888
Fuzzy Cognitive Maps (FCMs) are a soft computing technique that follows an approach similar to human reasoning and human decision-making\\u000a process, considering them a valuable modeling and simulation methodology. FCMs can successfully represent knowledge and experience,\\u000a introducing concepts for the essential elements and through the use of cause and effect relationships among the concepts Medical\\u000a Decision Systems are complex systems
The use of computer-based decision support programs in medicine will result in litigation when adverse health care outcomes\\u000a affect patients. This paper reviews how the United States legal system is likely to handle such cases. To date, there is minimal\\u000a direct experience with such cases in the American legal system. Medicaldecision support systems are more likely to be viewed
Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes. PMID:22837104
Stein, Bradley D; Kogan, Jane N; Mihalyo, Mark J; Schuster, James; Deegan, Patricia E; Sorbero, Mark J; Drake, Robert E
The changing doctor-patient relationship and commercialization of modern medical practice has affected the practice of medicine. On the one hand, there can be unfavorable results of treatment and on the other hand the patient suspects negligence as a cause of their suffering. There is an increasing trend of medical litigation by unsatisfied patients. The Supreme Court has laid down guidelines for the criminal prosecution of a doctor. This has decreased the unnecessary harassment of doctors. As the medical profession has been brought under the provisions of the Consumer Protection Act, 1986, the patients have an easy method of litigation. There should be legal awareness among the doctors that will help them in the proper recording of medical management details. This will help them in defending their case during any allegation of medical negligence.
A survey of 500 respondents from Beijing, China, was conducted to investigate their perceptions of the functions and consequences of pharmaceutical advertising and their medicaldecisions. Results indicated that Chinese consumers held a very positive attitude toward advertising in general, as well as toward pharmaceutical advertising in particular. Pharmaceutical advertising was most readily accepted as information for brand differentiation and
This paper introduces javelin diagrams as an innovative way for depicting the results of medicaldecision analyses. The methods were used to determine whether, and at which values, blood lactate in Belgian White and Blue or maximum tidal volumes in Holstein calves should be measured before deciding to treat or not a calf suffering from the bovine respiratory disease complex.
The author examined relationships between adverse medical events (AMEs) on discharge decisions. Using secondary data capturing inpatient utilization from Oklahoma hospitals, the author employed logistic regression to estimate the probability of extended hospital stay and the need for postacute care as a function of AMEs, and multiple regression analysis to assess the effect of AMEs on the number of days
Robert W. Broyles; Ann F. Chou; Steve E. Mattachione; A. F. Al-Assaf
BACKGROUND Medicationdecision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medicationdecision making. OBJECTIVE To explore the views of older adults regarding participation in medicationdecision making. DESIGN Qualitative study. PARTICIPANTS Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices. APPROACH One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis. RESULTS The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making. CONCLUSIONS While evolution to greater patient involvement in medicationdecision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.
Belcher, Vernee N; Fried, Terri R; Agostini, Joseph V; Tinetti, Mary E
We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medicaldecisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medicaldecision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research. PMID:19883143
Reyna, Valerie F; Nelson, Wendy L; Han, Paul K; Dieckmann, Nathan F
We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medicaldecisions. Low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication (limiting prevention efforts among the most vulnerable), and, based on the scant research conducted on outcomes, appears to adversely affect medical outcomes. Low numeracy is also associated with greater susceptibility to extraneous factors (i.e., factors that do not change the objective numerical information). That is, low numeracy increases susceptibility to effects of mood or how information is presented (e.g., as frequencies vs. percentages) and to biases in judgment and decision making (e.g., framing and ratio bias effects). Much of this research is not grounded in empirically supported theories of numeracy or mathematical cognition, which are crucial for designing evidence-based policies and interventions that are effective in reducing risk and improving medicaldecision making. To address this gap, we outline four theoretical approaches (psychophysical, computational, standard dual-process, and fuzzy trace theory), review their implications for numeracy, and point to avenues for future research.
Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Dieckmann, Nathan F.
In a previous issue of The Journal, I anticipated the decision of the Ninth Circuit in United States v. Loughner. The Ninth Circuit's opinion upheld the involuntary medication of Mr. Loughner under a Harper order, with awareness that he could thereby gain trial competence, and it allowed Mr. Loughner's extended commitment to Federal Medical Center (FMC)-Springfield for the purpose of rendering him trial competent. As also anticipated in that article, the Ninth Circuit did not comment on the medical appropriateness of the setting for involuntary medication of pretrial defendants or its own court order permitting the involuntary medication of Mr. Loughner in a nonmedical correctional facility. In this article, the Ninth Circuit's opinion is analyzed with respect to its potential effect on the medical appropriateness of the setting, medical versus nonmedical, for involuntary medication with antipsychotic agents of pretrial defendants. Although the likelihood of Supreme Court review of the Loughner case has been made nil by his guilty plea, this case raises an unresolved constitutional point as well as the question of whether involuntary medical treatment should be administered in a setting that is appropriate for such treatment. PMID:23503184
Medicaldecision making can be regarded as a process, combining both analytical cognition and intuition. It involves reasoning within complex causal models of multiple concepts, usually described by uncertain, imprecise, and/or incomplete information. Aiming to model medicaldecision making, we propose a novel approach based on cognitive maps and intuitionistic fuzzy logic. The new model, called intuitionistic fuzzy cognitive map (iFCM), extends the existing fuzzy cognitive map (FCM) by considering the expert's hesitancy in the determination of the causal relations between the concepts of a domain. Furthermore, a modification in the formulation of the new model makes it even less sensitive than the original model to missing input data. To validate its effectiveness, an iFCM with 34 concepts representing fuzzy, linguistically expressed patient-specific data, symptoms, and multimodal measurements was constructed for pneumonia severity assessment. The results obtained reveal its comparative advantage over the respective FCM model by providing decisions that match better with the ones made by the experts. The generality of the proposed approach suggests its suitability for a variety of medicaldecision-making tasks. PMID:21095874
Objective: Patients with malignant glioma (MG) must make ongoing medical treatment decisions concerning a progressive disease that erodes cognition. We prospectively assessed medicaldecision-making capacity (MDC) in patients with MG using a standardized psychometric instrument. Methods: Participants were 22 healthy controls and 26 patients with histologically verified MG. Group performance was compared on the Capacity to Consent to Treatment Instrument (CCTI), a psychometric measure of MDC incorporating 4 standards (choice, understanding, reasoning, and appreciation), and on neuropsychological and demographic variables. Capacity outcomes (capable, marginally capable, or incapable) on the CCTI standards were identified for the MG group. Within the MG group, scores on demographic, clinical, and neuropsychological variables were correlated with scores on each CCTI standard, and significant bivariate correlates were subsequently entered into exploratory stepwise regression analyses to identify multivariate cognitive predictors of the CCTI standards. Results: Patients with MG performed significantly below controls on consent standards of understanding and reasoning, and showed a trend on appreciation. Relative to controls, more than 50% of the patients with MG demonstrated capacity compromise (marginally capable or incapable outcomes) in MDC. In the MG group, cognitive measures of verbal acquisition/recall and, to a lesser extent, semantic fluency predicted performance on the appreciation, reasoning, and understanding standards. Karnofsky score was also associated with CCTI performance. Conclusions: Soon after diagnosis, patients with malignant glioma (MG) have impaired capacity to make treatment decisions relative to controls. Medicaldecision-making capacity (MDC) impairment in MG seems to be primarily related to the effects of short-term verbal memory deficits. Ongoing assessment of MDC in patients with MG is strongly recommended. GLOSSARY AED = antiepileptic drug; BDI = Beck Depression Inventory; CCTI = Capacity to Consent to Treatment Instrument; GBM = glioblastoma multiforme; HVLT = Hopkins Verbal Learning Test; MDC = medicaldecision-making capacity; MG = malignant glioma; UAB = University of Alabama at Birmingham.
Triebel, Kristen L.; Martin, Roy C.; Nabors, Louis B.; Marson, Daniel C.
Development of clinical decision support systems (CDS) is a process which highly depends on the local databases, this resulting in low interoperability. To increase the interoperability of CDS a standard representation of clinical information is needed. The paper suggests a CDS architecture which integrates several HL7 standards and the new vMR (virtual Medical Record). The clinical information for the CDS systems (the vMR) is represented with Topic Maps technology. Beside the implementation of the vMR, the architecture integrates: a Data Manager, an interface, a decision making system (based on Egadss), a retrieving data module. Conclusions are issued. PMID:22874164
Gomoi, Valentin-Sergiu; Dragu, Daniel; Stoicu-Tivadar, Vasile
In recent years personal and clinical dilemmas relating to terminally ill patient-care medical, decisions have increased significantly. Although understanding the patient's medical, nursing and, social background is important, a comprehensive appraisal essential for treating the "whole patient" is, incomplete without a spirituality assessment. Religious beliefs and practices affect medical and health, care decisions and require recognition as a dynamic in coping with suffering, loss, life, and death. Taking a spiritual background obtains information that is meaningful to the patient's life and may, influence the medicaldecision-making relating to health. A study was undertaken to determine, whether assessing the spiritual background influences medicaldecisions-making regarding the use of, DNR. The target population was 46 family-member caregivers of non-communicative patients in the Herzog, Hospital Skilled Nursing ward located in Jerusalem. The spiritual assessment questionnaire was the, acronym FICA (faith, importance, community and addressing). Two-thirds of the families were opposed to a determination utilizing do not resuscitate (DNR). Multivariate, analysis of the findings found that only religious affiliation was statistically significant (p=0.003). The doctors recommend DNR in 67% of the cases while the family caregiver accepted this decision in, only 33% of the cases. The hypothesis was verified. People who are perceived as being religious or as being greatly influenced, by faith/spirituality opposed the recommendation implementing DNR. Obtaining a spiritual background assists the physician to understand the patient or family spirituality, facilitates sensitivity to value frameworks and preferences in making medical and health-related, decisions. PMID:24029615
This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time pressure, implicit biases regarding blacks and Hispanics led to a less serious diagnosis. In addition, implicit biases regarding blacks led to a lower likelihood of a referral to specialist when physicians were under high time pressure. The results suggest that when physicians face stress, their implicit biases may shape medicaldecisions in ways that disadvantage minority patients. PMID:22811465
The framing effect, identified by Tversky and Kahneman, is one of the most striking cognitive biases, in which people react differently to a particular choice depending whether it is presented as a loss or as a gain. Numerous studies have subsequently demonstrated the robustness of the framing effect in a variety of contexts, especially in medicaldecision-making. Compared to daily decisions, medicaldecisions are of low frequency but of paramount importance. The framing effect is a well-documented bias in a variety of studies, but research is inconsistent regarding whether and how variables influence framing effects in medicaldecision-making. To clarify the discrepancy in the previous literature, published literature in the English language concerning the framing effect was retrieved using electronic and bibliographic searches. Two reviewers examined each article for inclusion and evaluated the articles' methodological quality. The framing effect in medicaldecision-making was reviewed in these papers. No studies identified an influence of framing information upon compliance with health recommendations, and different studies demonstrate different orientations of the framing effect. Because so many variables influence the presence or absence of the framing effect, the unexplained heterogeneity between studies suggests the possibility of a framing effect under specific conditions. Further research is needed to determine why the framing effect is induced and how it can be precluded. PMID:23387993
We propose a methodology for making optimal registration decisions during 3D volume reconstruction in terms of (a) anticipated accuracy of aligned images, (b) uncertainty of obtained results during the registration process, (c) algorithmic repeatability of alignment procedure, and (d) computational requirements. We researched and developed a web-enabled, web services based, data-driven, registration decision support system. The registration decisions include (1) image spatial size (image sub-area or entire image), (2) transformation model (e.g., rigid, affine or elastic), (3) invariant registration feature (intensity, morphology or a sequential combination of the two), (4) automation level (manual, semi-automated, or fully-automated), (5) evaluations of registration results (multiple metrics and methods for establishing ground truth), and (6) assessment of resources (computational resources and human expertise, geographically local or distributed). Our goal is to provide mechanisms for evaluating the tradeoffs of each registration decision in terms of the aforementioned impacts. First, we present a medical registration methodology for making registration decisions that lead to registration results with well-understood accuracy, uncertainty, consistency and computational complexity characteristics. Second, we have built software tools that enable geographically distributed researchers to optimize their data-driven registration decisions by using web services and supercomputing resources. The support developed for registration decisions about 3D volume reconstruction is available to the general community with the access to the NCSA supercomputing resources. We illustrate performance by considering 3D volume reconstruction of blood vessels in histological sections of uveal melanoma from serial fluorescent labeled paraffin sections labeled with antibodies to CD34 and laminin. The specimens are studied by fluorescence confocal laser scanning microscopy (CLSM) images.
To examine the relationships between Alzheimer's disease (AD) severity and patient participation in decisions about their medical care, we performed a cross-sectional study of 74 caregivers' ratings of the degree to which AD patients participate in making decisions about their medical care. The majority of the caregivers reported that they made the final decisions about medical care (n = 48,
Jason H. T. Karlawish; David Casarett; Kathleen Joy Propert; Bryan D. James; M. Bioethics; Christopher M. Clark
Over the past several decades, there has been a steady increase in the use of medication therapy to help control student behavior within schools. While psychotropic medications do not "cure" mental illnesses, they have demonstrated efficacy in helping children function better at school and within their home environment. However, it is important…
Fuzzy Cognitive Maps (FCMs) are an efficient modeling method providing flexibility on the simulated system's design. They consist of nodes-concepts and weighted edges that connect the nodes and represent the cause and effect relationships among them. The performance of FCMs is dependent on the initial weight setting and architecture. This shortcoming can be alleviated and the FCM model can be enhanced if a fuzzy rule base (IF-THEN rules) is available. This research proposes a successful attempt to combine fuzzy cognitive maps with decision tree generators. A combined Decision Tree-Fuzzy Cognitive Map (DT-FCM) model is proposed when different types of input data are available and the behavior of this model is studied. In this research work, we introduce a new hybrid modeling methodology for decision making tasks and we implement the proposed methodology at a medical problem. PMID:17946358
Papageorgiou, Elpiniki; Stylios, Chrysostomos; Groumpos, Peter
The medical library assumes increasing importance to teaching and research. While funds for research, medical education, and improved facilities for patients have been increasing and are relatively easy to obtain, however, it has been extraordinarily difficult to obtain funds for the building and maintenance of medical libraries. The National Library of Medicine is attempting to preserve the record of medical knowledge and by means of mechanization provide more efficient service to physicians and scientists, but one, or a few, great libraries cannot serve the medical interests of the country. Federal support such as the program of grants in the proposed Medical Library Assistance Act is needed to assist local and regional efforts to improve library service.
Introduction: To determine emergency physician (EP) opinions of prehospital patient care reports (PCRs) and whether such reports are available at the time of emergency department (ED) medicaldecision-making. Methods: Prospective, cross-sectional, electronic web-based survey of EPs regarding preferences and availability of prehospital PCRs at the time of ED medicaldecision-making. Results: We sent the survey to 1,932 EPs via 4 American College of Emergency Physicians (ACEP) email lists. As a result, 228 (11.8%) of email list members from 31 states and the District of Columbia completed the survey. Most respondents preferred electronic prehospital PCRs as opposed to handwritten prehospital PCRs (52.2% [95% confidence interval (CI): 49.1, 55.3] vs. 17.1% [95%CI: 11.7, 22.5]). The remaining respondents (30.5% [95%CI: 26.0, 35.0]) had no preference or had seen only one type of PCR. Of the respondents, 45.6% [95%CI: 42.1, 48.7] stated PCRs were “very important” while 43.0% [95% CI: 39.3, 46.7] rated PCRs as “important” in their ED practice. Most respondents (79.6% [95%CI: 76.5, 82.7]) reported electronic prehospital PCRs were available ?50% of the time for medicaldecision-making while 20.4% [95%CI: 9.2, 31.6] reported that electronic prehospital PCRs were available > 50% of the time (P=0.00). A majority of participants (77.6% [95%CI: 74.5, 80.7]) reported that handwritten prehospital PCRs were available ? 50% while 22.4% [95%CI: 11.8, 33.0] of the time for medicaldecision-making (P=0.00). Conclusion: EPs in this study felt that prehospital PCRs were important to their ED practice and preferred electronic prehospital PCRs over handwritten PCRs. However, most electronic prehospital PCRs were unavailable at the time of ED medicaldecision-making. Although handwritten prehospital PCRs were more readily available, legibility and accuracy were reported concerns. This study suggest that strategies should be devised to improve the overall accuracy of PCRs and assure that electronic prehospital PCRs are delivered to the receiving ED in time for consideration in ED medicaldecision-making.
This is the second of two linked papers exploring decision making in nursing. The first paper, 'Classifying clinical decision making: a unifying approach' investigated difficulties with applying a range of decision-making theories to nursing practice. This is due to the diversity of terminology and theoretical concepts used, which militate against nurses being able to compare the outcomes of decisions analysed within different frameworks. It is therefore problematic for nurses to assess how good their decisions are, and where improvements can be made. However, despite the range of nomenclature, it was argued that there are underlying similarities between all theories of decision processes and that these should be exposed through integration within a single explanatory framework. A proposed solution was to use a general model of psychological classification to clarify and compare terms, concepts and processes identified across the different theories. The unifying framework of classification was described and this paper operationalizes it to demonstrate how different approaches to clinical decision making can be re-interpreted as classification behaviour. Particular attention is focused on classification in nursing, and on re-evaluating heuristic reasoning, which has been particularly prone to theoretical and terminological confusion. Demonstrating similarities in how different disciplines make decisions should promote improved multidisciplinary collaboration and a weakening of clinical elitism, thereby enhancing organizational effectiveness in health care and nurses' professional status. This is particularly important as nurses' roles continue to expand to embrace elements of managerial, medical and therapeutic work. Analysing nurses' decisions as classification behaviour will also enhance clinical effectiveness, and assist in making nurses' expertise more visible. In addition, the classification framework explodes the myth that intuition, traditionally associated with nurses' decision making, is less rational and scientific than other approaches. PMID:11095240
|A thin layer chromatography experiment of medicalimportance is described. The experiment involves extraction of lipids from simulated amniotic fluid samples followed by separation, detection, and scanning of the lecithin and sphingomyelin bands on TLC plates. The lecithin-to-sphingomyelin ratio is calculated. The clinical significance of this…
A thin layer chromatography experiment of medicalimportance is described. The experiment involves extraction of lipids from simulated amniotic fluid samples followed by separation, detection, and scanning of the lecithin and sphingomyelin bands on TLC plates. The lecithin-to-sphingomyelin ratio is calculated. The clinical significance of this…
Background: Student decisions about lecture attendance are based on anticipated effect on learning. Factors involved in decision-making, the use of recorded lectures and their effect on lecture attendance, all warrant investigation. Aim: This study was designed to identify factors in student decisions to attend live lectures, ways in which students use recorded lectures, and if their use affects live lecture attendance. Methods: A total of 213 first (M1) and second year (M2) medical students completed a survey about lecture attendance, and rated factors related to decisions to attend live lectures and to utilize recorded lectures. Responses were analyzed overall and by class year and gender. Results: M1 attended a higher percentage of live lectures than M2, while both classes used the same percentage of recorded lectures. Females attended more live lectures, and used a smaller percentage of recorded lectures. The lecturer was a key in attendance decisions. Also considered were the subject and availability of other learning materials. Students use recorded lectures as replacement for live lectures and as supplement to them. Conclusions: Lectures, both live and recorded, are important for student learning. Decisions about lecture placement in the curriculum need to be based on course content and lecturer quality. PMID:23869431
Background: Although physicians sometimes use the futility rationale to limit the use of life-sustaining treatments, little is known about how surrogate decision makers view this rationale. We sought to determine the attitudes of surrogates of patients who are critically ill toward whether physicians can predict futility and whether these attitudes predict surrogates' willingness to discontinue life support when faced with predictions of futility. Methods: This multicenter, mixed qualitative and quantitative study took place at three hospitals in California from 2006 to 2007. We conducted semistructured interviews with surrogate decision makers for 50 patients who were critically ill and incapacitated that addressed their beliefs about medical futility and inductively developed an organizing framework to describe these beliefs. We used a hypothetical scenario with a modified time–trade-off design to examine the relationship between a patient's prognosis and a surrogate's willingness to withdraw life support. We used a mixed-effects regression model to examine the association between surrogates' attitudes about futility and their willingness to limit life support in the face of a very poor prognosis. Validation methods included the use and integration of multiple data sources, multidisciplinary analysis, and member checking. Results: Sixty-four percent of surrogates (n = 32; 95% confidence interval [CI], 49 to 77%) expressed doubt about the accuracy of physicians' futility predictions, 32% of surrogates (n = 16; 95% CI, 20 to 47%) elected to continue life support with a < 1% survival estimate, and 18% of surrogates (n = 9; 95% CI, 9 to 31%) elected to continue treatment when the physician believed that the patient had no chance of survival. Surrogates with religious objections to the futility rationale (n = 18) were more likely to request continued life support (odds ratio, 4; 95% CI, 1.2 to 14.0; p = 0.03) than those with secular or experiential objections (n = 15; odds ratio, 0.95; 95% CI, 0.3 to 3.4; p = 0.90). Conclusions: Doubt about physicians' ability to predict medical futility is common among surrogate decision makers. The nature of the doubt may have implications for responding to conflicts about futility in clinical practice.
Zier, Lucas S.; Burack, Jeffrey H.; Micco, Guy; Chipman, Anne K.; Frank, James A.; White, Douglas B.
Clinical evidence suggests that many patients undergo surgery that they would decline if fully informed. Failure to communicate the relevant risks, benefits, and alternatives of a procedure violates medical ethics and wastes medical resources. Integrating shared decision-making, a method of communication between provider and patient, into medicaldecisions can satisfy physicians' ethical obligations and reduce unwanted procedures. This article proposes a three-step process for implementing a nationwide practice of shared decision-making: (1) create model integration programs; (2) provide legal incentives to ease the transition; and (3) incorporate shared decision-making into medical necessity determinations. PMID:20446987
The peroxisome has long been known for its role in lipid metabolism and hydrogen peroxide detoxification. However, growing evidence supports the view that this organelle can also function both as an intracellular signaling compartment and as an organizing platform that orches- trates certain developmental decisions from inside the cell. This review highlights various strategies that peroxisomes employ to regulate the
A group decision support system (GDSS) framework to support medicaldecision making (MDM) based on cognitive characteristics incorporating clinical reasoning and problem solving features is presented. The role of cognitive processes which are inherent in MDM has influenced the development of this framework. The three key components of this framework are: “cognitive aid structures”, “cognitive appropriation” and “GDSS support structures”.
The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medicaldecision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviors or in supporting medicaldecision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components.
The tenets of fuzzy trace theory are summarized with respect to their relevance to health and medicaldecision making. Illustrations are given for HIV prevention, cardiovascular disease, surgical risk, genetic risk, and cancer prevention and control. A core idea of fuzzy trace theory is that people rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decision making. This idea explains why precise information (e.g., about risk) is not necessarily effective in encouraging prevention behaviors or in supporting medicaldecision making. People can get the facts right, and still not derive the proper meaning, which is key to informed decision making. Getting the gist is not sufficient, however. Retrieval (e.g., of health-related values) and processing interference brought on by thinking about nested or overlapping classes (e.g., in ratio concepts, such as probability) are also important. Theory-based interventions that work (and why they work) are presented, ranging from specific techniques aimed at enhancing representation, retrieval, and processing to a comprehensive intervention that integrates these components. PMID:19015287
While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must
GILAD J. KUPERMAN; ANNE BOBB; T HOMAS H. PAYNE; ANTHONY J. AVERY; TEJAL K. GANDHI; GERARD BURNS; DAVID C. CLASSEN; DAVID W. BATES
The professional identity of psychiatry depends on it being regarded as one amongst many medical specialties and sharing ideals of good practice with other specialties, an important marker of which is the achievement of shared decision-making and avoiding a reputation for being purely agents of social control. Yet the interactions involved in trying to achieve shared decision-making are relatively unexplored in psychiatry. This study analyses audiotapes of 92 outpatient consultations involving nine consultant psychiatrists focusing on how pressure is applied in shared decisions about antipsychotic medication. Detailed conversation analysis reveals that some shared decisions are considerably more pressured than others. At one end of a spectrum of pressure are pressured shared decisions, characterised by an escalating cycle of pressure and resistance from which it is difficult to exit without someone losing face. In the middle are directed decisions, where the patient cooperates with being diplomatically steered by the psychiatrist. At the other extreme are open decisions where the patient is allowed to decide, with the psychiatrist exerting little or no pressure. Directed and open decisions occurred most frequently; pressured decisions were rarer. Patient risk did not appear to influence the degree of pressure applied in these outpatient consultations. PMID:21812791
Articles about medical diagnostic decision support (MDDS) systems often begin with a disclaimer such as, "despite many years of research and millions of dollars of expenditures on medical diagnostic systems, none is in widespread use at the present time." While this statement remains true in the sense that no single diagnostic system is in widespread use, it is misleading with regard to the state of the art of these systems. Diagnostic systems, many simple and some complex, are now ubiquitous, and research on MDDS systems is growing. The nature of MDDS systems has diversified over time. The prospects for adoption of large-scale diagnostic systems are better now than ever before, due to enthusiasm for implementation of the electronic medical record in academic, commercial, and primary care settings. Diagnostic decision support systems have become an established component of medical technology. This paper provides a review and a threaded bibliography for some of the important work on MDDS systems over the years from 1954 to 1993.
Simulation modeling can be used in aiding decision-makers in deciding when to invest in additional research and when the risky animal disease-importdecision should go forward. Simulation modeling to evaluate value-of-information (VOI) techniques provides a robust, objective and transparent framework for assisting decision-makers in making risky animal and animal product decisions.In this analysis, the hypothetical risk from poultry disease in
The medical diagnosis by nature is a complex and fuzzy cognitive process, and soft computing methods, such as neural networks, have shown great potential to be applied in the development of medicaldecision support systems (MDSS). In this paper, a multiplayer perceptron- based decision support system is developed to support the diagnosis of heart diseases. The input layer of the
Hongmei Yana; Yingtao Jiang; Jun Zhenge; Chenglin Peng; Qinghui Li
Abstract The medical diagnosis by nature is a complex and fuzzy cognitive process, and soft computing methods, such as neural networks, have shown great potential to be applied in the development of medicaldecision support systems (MDSS). In this paper, a multiplayer perceptron- based decision support system is developed,to support the diagnosis of heart diseases. The input layer of the
Hongmei Yan; Yingtao Jiang; Jun Zheng; Chenglin Peng; Qinghui Li
Since medical field is highly professional, the me dical service provider thus owns professional knowledge much higher than the consumers and information asymmetric nature is thus one of the major features in medical field. Systematic decision-making analysis can help decision maker to summarize and judge all information effectively and to define right question and to find out optimum and the
This work relates to the development of computational algorithms to provide decision support to physicians. The authors propose a Fuzzy Naive Bayesian (FNB) model for medical diagnosis, which extends the Fuzzy Bayesian approach proposed by Okuda. A physician's interview based method is described to define a orthogonal fuzzy symptom information system, required to apply the model. For the purpose of elaboration and elicitation of characteristics, the algorithm is applied to a simple simulated dataset, and compared with conventional Naive Bayes (NB) approach. As a preliminary evaluation of FNB in real world scenario, the comparison is repeated on a real fuzzy dataset of 81 patients diagnosed with infectious diseases. The case study on simulated dataset elucidates that FNB can be optimal over NB for diagnosing patients with imprecise-fuzzy information, on account of the following characteristics - 1) it can model the information that, values of some attributes are semantically closer than values of other attributes, and 2) it offers a mechanism to temper exaggerations in patient information. Although the algorithm requires precise training data, its utility for fuzzy training data is argued for. This is supported by the case study on infectious disease dataset, which indicates optimality of FNB over NB for the infectious disease domain. Further case studies on large datasets are required to establish utility of FNB. PMID:19963578
Wagholikar, Kavishwar B; Vijayraghavan, Sundararajan; Deshpande, Ashok W
Objective Many laypeople demonstrate excessive sensitivity to negative side effects of medical treatments, which may lead them to refuse beneficial therapies. This Internet-based experiment investigated three possible explanations for such “side effect aversion.” One was derived from mental accounting, one examined the mere presence of a side effect, and one focused on computational difficulties. Design Participants (N = 5,379) were presented with a hypothetical cancer preventive treatment situation that was or was not accompanied by one or two small side effects. The side effects were either beneficial or harmful. In all conditions the net absolute risk reduction associated with the treatment was 15%. Main Outcome Measures Participants indicated their willingness to accept treatment and their perceptions of the treatment’s effects on their overall cancer risk. Results Data were consistent only with the “mere presence” explanation of side effect aversion, the idea that side effects act as a strong negative cue that directly affects treatment appraisal. The number of negative side effects did not influence treatment willingness. Conclusion Side effect aversion is a challenge to informed decision making. Specific mechanisms that produce side effect aversion should be identified.
Waters, Erika A.; Weinstein, Neil D.; Colditz, Graham A.; Emmons, Karen
The medicaldecision-making process is currently in flux. Decisions are no longer made entirely at the physician's discretion: patients are becoming more and more involved in the process. There is a great deal of discussion about the ideal of ‘informed consent’, that is that diagnostic and therapeutic decisions should be made based on an interaction between physician and patient. This
In 1996, shortly after the San Francisco Cannabis Club was raided and (temporarily) closed by state authorities, the authors conducted an ethnographic study by interviewing selected former members to ascertain how they had benefited from the use of medical marijuana and how they had utilized the clubs. Interviews were augmented by participant observation techniques. Respondents reported highly positive health benefits from marijuana itself, and underscored even greater benefits from the social aspects of the clubs, which they described as providing important emotional supports. As such, cannabis clubs serve as crucial support mechanisms/groups for people with a wide variety of serious illnesses and conditions. The authors concluded that of the various methods so far proposed, the cannabis clubs afford the best therapeutic setting for providing medical cannabis and for offering a healing environment composed of like-minded, sympathetic friends. PMID:9692380
A decision analysis was conducted on the specific diagnostic category of hypertension to obtain optimal diagnosis-treatment procedures. Emphasis was placed on the problem formulation phase of the decision analysis. Twelve categories of sustained diastolic...
This study investigates the influences of perceptions regarding the importance of ethics and social responsibility on ethical intentions of marketing professionals. It also investigates the effects of perceived ethical problems and gender on ethical intentions. The results, based on a survey of practitioner members of the American Marketing Association, revealed that a marketing professional’s perception regarding the importance of ethics
|Outdoor leaders function in naturalistic decision-making contexts and may be influenced by personal, social, and environmental factors in making critical decisions in the field. The experience level of the outdoor instructor is posited as a critical variable in the development of his/her decision-making and overall judgment. This research…
Guidelines in medicine have been proposed as a way to assist physicians in the clinical decision-making process. Increasingly, they form the basis for assessing accountability in the delivery of healthcare services. However, experiences with their evaluation, as the most important step in the continuous guidelines process, are rare. Patient Care Evaluation Studies have been developed by the Commission on Cancer in the United States. As they reflect the "real-world" medical practice they are helpful in evaluating the quality of diagnosis, therapy and follow-up of tumor diseases in hospitals and cancer center and the compliance with current standards of care. In this context, they can provide an infrastructure for the analysis of the decision-making process.
Holzer, S.; Fremgen, A. M.; Hundahl, S. A.; Dudeck, J.
Selected segments of any DNA molecule can be amplified exponentially by PCR. This technique provides a powerful tool to detect and identify minimal numbers of microorganisms. PCR is applicable both in diagnosis and in epidemiology. By amplification of hypervariable DNA domains, differences can be detected even among closely related strains. PCR fingerprinting is a valuable tool for medical microbiologists, epidemiologists, and microbial taxonomists. The current state of PCR-mediated genotyping is reviewed, and a comparison with conventional molecular typing methods is included. Because of its speed and versatility, PCR fingerprinting will play an important role in microbial genetics, epidemiology, and systematics. Images
During a taxonomic investigation of Nocardia spp. and Streptomyces spp., we received 658 isolates from laboratories of both human and veterinary medicine. Our procedure leading to the identification of 92% of these isolates, the species that they represented, and a characteristic pattern of properties of the strains of these species are presented. A key devised for the tentative identification of species of nocardiae and streptomycetes that are believed to be of medicalimportance is included to assist clinical microbiologists in identifying their strains. Images
AIM: Young people are often seen as an important target for prevention of overweight, but we know little about the factors which are important for their weight management decisions. This study aimed to evaluate the extent to which elements of body composition and dimensions were implicated in their decisions to change their weight.PARTICIPANTS: Participants were 116 male and 126 female
Attempts to predict the future are typically off the mark. Beyond the challenges of forecasting the stock market or the weather, dramatic instances of notoriously inaccurate prognostications have been those by the US patent office in the late 1800s about the future of inventions, by Thomas Watson in the 1930s about the market for large computers, and by Bill Gates in the early 1990s about the significance of the Internet. When one seeks to make predictions about health care, one finds that, beyond the usual uncertainties regarding the future, additional impediments to forecasting are the discontinuities introduced by advances in biomedical science and technology, the impact of information technology, and the reorganizations and realignments attending various approaches to health care delivery and finance. Changes in all three contributing areas themselves can be measured in "PSPYs", or paradigm shifts per year. Despite these risks in forecasting, I believe that certain trends are sufficiently clear that I am willing to venture a few predictions. Further, the predictions I wish to make suggest a goal for the future that can be achieved, if we can align the prevailing political, financial, biomedical, and technical forces toward that end. Thus, in a sense this is a call to action, to shape the future rather than just let it happen. This chapter seeks to lay out the direction we are heading in knowledge management and decision support, and to delineate an information technology framework that appears desirable. I believe the framework to be discussed is of importance to the health care-related knowledge management and decision making activities of the consumer and patient, the health care provider, and health care delivery organizations and insurers. The approach is also relevant to the other dimensions of academic health care institution activities, notably the conduct of research and the processes of education and learning. PMID:12026135
As technology evolves, the role of medical equipment in the healthcare system, as well as technology management, becomes more important. Although the existence of large databases containing management information is currently common, extracting useful information from them is still difficult. A useful tool for identification of frequently failing equipment, which increases maintenance cost and downtime, would be the classification according to the corrective maintenance data. Nevertheless, establishment of classes may create inconsistencies, since an item may be close to two classes by the same extent. Paraconsistent logic might help solve this problem, as it allows the existence of inconsistent (contradictory) information without trivialization. In this paper, a methodology for medical equipment classification based on the ABC analysis of corrective maintenance data is presented, and complemented with a paraconsistent annotated logic analysis, which may enable the decision maker to take into consideration alerts created by the identification of inconsistencies and indeterminacies in the classification. PMID:22407498
Oshiyama, Natália F; Bassani, Rosana A; D'Ottaviano, Itala M L; Bassani, José W M
People use arguments to justify their claims. Computer systems use explanations to justify their conclusions. We are developing WOZ, an explanation framework that justifies the conclusions of a clinical decision-support system. WOZ's central component is the explanation strategy that decides what information justifies a claim. The strategy uses Toulmin's argument structure to define pieces of information and to orchestrate their presentation. WOZ uses explicit models that abstract the core aspects of the framework such as the explanation strategy. In this paper, we present the use of arguments, the modeling of explanations, and the explanation process used in WOZ. WOZ exploits the wealth of naturally occurring arguments, and thus can generate convincing medical explanations. Images Figure 5
In this study, women age 35 or older who discuss the use of drugs called SERMs for breast cancer prevention with a health care provider will be asked to complete a questionnaire about their discussion and whether they have come to a decision about using a SERM for risk reduction, as well as a second questionnaire about their decision-making process.
The decision tree approach is one of the most common approaches in automatic learning and decision making. The automatic learning of decision trees and their use usually show very good results in various “ theoretical” environments. But in real life it is often impossible to find the desired number of representative training objects for various reasons. The lack of possibilities
Milan Zorman; Milojka Molan Štiglic; Peter Kokol; Ivan Mal?i?
While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs.To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand
Gilad J. Kuperman; Anne M. Bobb; Thomas H. Payne; Anthony J. Avery; Tejal K. Gandhi; Gerard Burns; David C. Classen; David W. Bates
For several years now, users have been waiting for standards allowing medical images to be exchanged, managed, stored and manipulated. Standards are prerequisites for the development of PACS and IMACS systems. It is because of the lack of standards that PACS have not yet widely been implemented. The ACR-NEMA committee (American College of Radiology--National Electronical Manufactures Association) are developing an image communication standard: DICOM 3.0. This should allow interconnection of different imaging modalities and other PACS nodes. Part of the DICOM 3.0 work will be demonstrated at RSNA 93 with involvement of Europe. In the European Standardization Committee (CEN), the technical committee responsible for the standardization activities in Medical Informatics (CEN TC 251), has agreed upon the directions and the scopes to be followed in this field. They are described in the directory of the European standardization requirements for health care informatics and programme for the development of standard adopted on 28 February 1991 by CEN TC 251. Top-down objectives describe the common framework and items like terminology, security, while the more bottom-up oriented items describe fields like medical imaging and multi-media. Since CEN TC 251 started working, an important coordination took place between Europe and the US and Japan, resulting in a common future approach. CEN TC 251 is setting the scene for a more technologically independent standard on a mid term basis. This standard will first have to be proto-typed before it can be published, because it must be possible to implement the standard, too much complexity will not be accepted by the industry. The European imaging standardization work based on the ISO/IPI standard, will be briefly explained; as well as the general framework model and object oriented model; the interworking aspects, and the relation to ISO standards. One should realize be realised that a standard is needed, which is not too ambitious. Because DICOM 3.0 will be ready soon, Europe has decided to support these activities and will concentrate on the next step to be taken. PMID:8348909
Patients’ decision-making capacity is a common concern in acute-care settings, particularly when patients refuse recommended treatment. Competence, the legal analogue of decisional capacity, is often misunderstood. Common misconceptions include a view that medicaldecision making is a global and permanent condition determined by psychiatrists. The role of the family in deciding capacity has also been an arbitrary issue. Basic dimensions
We address the problem of optimal registration decisions during 3D medical volume reconstruction and their impact on anticipated accuracy of aligned images, uncertainty of obtained results, repeatability of alignment, and computational requirements. The registration decisions include image size used for regis- tration, transformation model, invariant registration feature (intensity or morphology), automation level, evaluations of registration results (multiple metrics and methods
This paper addresses the problem of understanding preservation and reconstruction requirements for computer- aided medicaldecision-making. With an increasing number of computer-aided decisions having a large impact on our society, the motivation for our work is not only to document these decision processes semi-automatically but also to understand the preservation cost and related computational requirements. Our objective is to support
When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the\\u000a course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients,\\u000a their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning\\u000a may be affected by undesired influences that may undermine
Heidi Albisser Schleger; Nicole R. Oehninger; Stella Reiter-Theil
We present a technique that enhances computer-assisted decision (CAD) systems with the ability to assess the reliability of each individual decision they make. Reliability assessment is achieved by measuring the accuracy of a CAD system with known cases similar to the one in question. The proposed technique analyzes the feature space neighborhood of the query case to dynamically select an input-dependent set of known cases relevant to the query. This set is used to assess the local (query-specific) accuracy of the CAD system. The estimated local accuracy is utilized as a reliability measure of the CAD response to the query case. The underlying hypothesis of the study is that CAD decisions with higher reliability are more accurate. The above hypothesis was tested using a mammographic database of 1337 regions of interest (ROIs) with biopsy-proven ground truth (681 with masses, 656 with normal parenchyma). Three types of decision models, (i) a back-propagation neural network (BPNN), (ii) a generalized regression neural network (GRNN), and (iii) a support vector machine (SVM), were developed to detect masses based on eight morphological features automatically extracted from each ROI. The performance of all decision models was evaluated using the Receiver Operating Characteristic (ROC) analysis. The study showed that the proposed reliability measure is a strong predictor of the CAD system's case-specific accuracy. Specifically, the ROC area index for CAD predictions with high reliability was significantly better than for those with low reliability values. This result was consistent across all decision models investigated in the study. The proposed case-specific reliability analysis technique could be used to alert the CAD user when an opinion that is unlikely to be reliable is offered. The technique can be easily deployed in the clinical environment because it is applicable with a wide range of classifiers regardless of their structure and it requires neither additional training nor building multiple decision models to assess the case-specific CAD accuracy.
Habas, Piotr A.; Zurada, Jacek M.; Elmaghraby, Adel S.; Tourassi, Georgia D. [Computational Intelligence Laboratory, Department of Electrical and Computer Engineering, University of Louisville, Louisville, Kentucky 40292 (United States); Department of Computer Engineering and Computer Science, University of Louisville, Louisville, Kentucky 40292 (United States); Digital Advanced Imaging Laboratories, Department of Radiology, Duke University Medical Center, Durham, North Carolina 27705 (United States)
|Introduction: Defined as reviews of clinical aspects of a specific health problem published in peer-reviewed and non-peer-reviewed medical journals, offered without charge, continuing medical education (CME) articles form a key strategy for translating knowledge into practice. This study assessed CME articles for mention of evidence-based…
We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical skills that are essential to maintain their health and make informed medical
Valerie F. Reyna; Wendy L. Nelson; Paul K. Han; Nathan F. Dieckmann
|Medical school admissions committees are expected to select physicians with specific attributes such as intelligence, altruism, dutifulness, and compassion. Besides basing these attributes on the best professional judgment of the physicians and medical school faculty, there has been little quantitative research to determine the psychological…
The biological control of insects carrying human diseases was first attempted many years ago, but the results were disappointing owing to the insufficiency of information on the ecology and pathology of such insects at the time. In recent years, however, increased knowledge of insect pathology and ecology and the development of insecticide-resistance have led to a revival of interest in this method of vector control. Most of the recent published work on this subject relates to findings in North America; comparatively little information has hitherto been available in respect of Europe. This paper, which is based on a survey of the literature and on the author's own experience, presents the results of research on diseases of insects of medicalimportance in Europe. Infection with viruses, rickettsiae, bacteria, fungi, protozoa and nematodes are discussed and suggested lines for future European research on biological control are put forward. ImagesFIG. 7-9FIG. 10-12FIG. 4-6FIG. 1-3
The acquisition of competence in radiology often entails referring to other realms of knowledge, by which insights are acquired through the use of metaphor. One way in which compelling associations are made and retained is by linking anatomic structures and pathologic conditions with objects, places, and concepts, and codifying these relationships as metaphoric signs. An aggregate of specialty-specific signs were obtained from two general medical dictionaries and from encyclopedic texts in radiology and six other specialties: internal medicine, dermatology, pathology, general surgery, orthopedics, and pediatrics. The signs were then separated into two categories: eponymous (bearing the name of an individual or place) and metaphoric (extending meaning from one context to another). A total of 375 metaphoric signs were collected from citations in the researched dictionaries and texts, the overwhelming majority (66%) of which were radiologic in reference. In every other specialty, eponymous signs outnumbered metaphoric signs. In contrast, eponymous signs were comparatively infrequent in radiology. The striking difference observed in the data highlights the importance of metaphors for discourse and instruction in radiology. In image interpretation, the meaning of perceptual input is often discerned through associations with pictures previously encountered and understood both concretely and metaphorically. The inherent nature of radiologic images as simulacra of both normal anatomy and disease entities makes imaging findings well suited to explanation by means of named patterns borrowed from other realms of knowledge. PMID:22236904
Human beings are more subjective than objective, In this paper, paying attention to our internal emotion, especially “subjectivity”, we introduce frame-oriented theory and show an application of the theory to decision processing and evaluation of medical diagnosis. Most medical diagnoses depend on the subjectivity of its specialist. Occasionally they are highly influenced by their subjectivity. Especially, a subjective diagnostic statement
The information needs of physicians are complex and ever increasing in a world of rapidly expanding medical knowledge and a practice environment where physicians are required to know and do more with shrinking resources. Current strategies for providing clinical decision support and continuing medical education have failed in part, because they have not provided timely, easy access to information that
Paul Godin; Robert Hubbs; Bill Woods; Mark C. Tsai; Dev Nag; Thomas C. Rindfleisch; Parvati Dev; Kenneth L. Melmon
|This paper examines how the exchange of information in medical interviews is organized, and how that organization produces and constrains the negotiation of treatment decisions. The analysis is drawn from the verbatim transcripts of audio-taped practitioner/patient communications, information gathered from medical files, and other ethnographic…
This paper examines how the exchange of information in medical interviews is organized, and how that organization produces and constrains the negotiation of treatment decisions. The analysis is drawn from the verbatim transcripts of audio-taped practitioner/patient communications, information gathered from medical files, and other ethnographic…
Aim: Previous studies indicate that Norwegian physicians hold conservative attitudes towards ethically controversial end-of-life decisions. The present study was undertaken to explore whether in Norway euthanasia may be hidden under labels such as death after analgesic injections and withholding or withdrawing treatment. Methods: A postal questionnaire containing 76 questions on ethical, collegial and professional autonomy issues was sent to a
Reidun Førde; Olaf G. Aasland; Petter Andreas Steen
Goals Decisions regarding adjuvant chemotherapy are difficult, since value tradeoffs are involved. Little is known about the importance\\u000a of the significant others in patients’ decision-making regarding adjuvant treatment. We surveyed patients with breast and\\u000a colorectal cancer about the importance they assigned to the opinions of their significant others and assessed correlates of\\u000a these importance scores.\\u000a \\u000a \\u000a \\u000a Materials and methods One hundred and twenty-three
A. M. Stiggelbout; S. J. T. Jansen; W. Otten; M. C. M. Baas-Thijssen; H. van Slooten
Gay, lesbian, bisexual and transgender (GLBT) patients have unique and different health needs other then those of the heterosexual patient. Although a significant proportion of the population is gay or lesbian, physicians receive little formal training about homosexuality, and the unique health care needs of these patients are often ignored. GLBT patients may have higher rates of depression, suicide attempts, alcoholism, and certain cancers, sexual transmitted and cardiovascular disease. One of the most significant medical risks of these populations is avoidance of routine health care and dissatisfaction due to fear of stigmatization by the medical community. Youth GBLT patients are particularly vulnerable to internal and external pressures, resulting in higher rates of substance and alcohol abuse, suicide, and homelessness. Declining health and loneliness may trouble older GBLT patients, who generally view themselves more positively. Physicians can improve the health care of GBLT patients and their families by maintaining a non-homophobic attitude toward these patients, distinguishing sexual behavior from sexual identity, communicating with gender-neutral terms, and maintaining awareness of how their own attitude affects clinical judgment. Scant research exists with regard to the best ways to teach medical students about the special challenge GBLT patients face. However, the recommendation is to integrate such teaching throughout the entire medical school curriculum. This article includes a summary of the medical literature for the GBLT patients' health care needs and suggests strategies for enhancing the care for this population, as well as incorporating it during the medical education. PMID:17853561
We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical…
Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Dieckmann, Nathan F.
In this paper we study how to detect anomalies in a distributed manner by using wireless sensor networks (WSNs). We focus on a medical context, where existing works generally provide large environments to monitor patients using sensors as simple transducers. Those devices forward sensed health parameters to a main base station. This station collects received data and may perform some
N. Dessart; Hacène Fouchal; Philippe Hunel; Harry Gros-Desormeaux; Nicolas Vidot
|We review the growing literature on health numeracy, the ability to understand and use numerical information, and its relation to cognition, health behaviors, and medical outcomes. Despite the surfeit of health information from commercial and noncommercial sources, national and international surveys show that many people lack basic numerical…
Reyna, Valerie F.; Nelson, Wendy L.; Han, Paul K.; Dieckmann, Nathan F.
|This study examined two types of potential sources of racial-ethnic disparities in medical care: implicit biases and time pressure. Eighty-one family physicians and general internists responded to a case vignette describing a patient with chest pain. Time pressure was manipulated experimentally. Under high time pressure, but not under low time…
The demand for global healthcare services is experiencing tremendous growth. US patients are seeking to reduce their expenditures on healthcare through obtaining treatment on an internationally competitive basis. This trend, known as medical tourism, is on the rise, and US legislators and policy makes must be aware of the issues facing American patients. This paper seeks to model factors that
A major obstacle in deploying computer-based clinical guidelines at the point of care is the variability of electronic medical records and the consequent need to adapt guideline modeling languages, guideline knowledge bases, and execution engines to idiosyncratic data models in the deployment environment. This paper reports an approach, developed jointly by researchers at Newcastle and Stanford, where guideline models are
AIM: To increase understanding of women's decision-making process concerning the medication use for anxiety and/or depression while pregnant. BACKGROUND: Anxiety and depression affects many pregnant women, yet the decision to take psychotropic medication is complex and possibly subject to social oppression. DESIGN: Cross-sectional descriptive survey design. METHODS: A web-based survey was used to collect data from a convenience sample of 143 pregnant women over 3 months beginning in early 2011. An independent t-test was conducted to determine differences in satisfaction between women with high and low levels of emancipated decision-making (EDM). A multiple regression analysis was conducted to determine which subscales of the emancipation scale best predict level of satisfaction with the decision. FINDINGS: The majority of respondents were White, between 25-34 years of age. The group with lower levels of emancipation reported lower mean satisfaction scores compared with those with higher levels of emancipation. Regression analysis showed that the three subscale emancipation model was a statistically significant predictor of satisfaction with the decision and accounted for 54% of the variance in satisfaction. The subconcept of personal knowledge was most predictive of satisfaction with decision. CONCLUSIONS: Women may be able to overcome oppressive forces by using an EDM process. EDM allows them to make a decision that feels right for them and to feel satisfied with the decision. PMID:23488910
Stepanuk, Kathleen M; Fisher, Kathleen M; Wittmann-Price, Ruth; Posmontier, Bobbie; Bhattacharya, Anand
The scientific and the medical communities are among the first asked both to advance highly specialized knowledge and to make it available to a wider community of users, accessing specialized knowledge and searching for single pieces of information for a whole variety of purposes that require diverse information needs and demands. Health advisors may want to update progress in research in a certain field of medicine, to ask experts the right kinds of questions and, even more fundamentally, to be able to describe those health problems they may encounter in their patients' community with words and expressions that can be both understandable and accurate. Researchers, physicians and nurses all face the need to share information that comes out of stabilized, or established, research, meaning research that has been accurately tested as opposed to new and untested assumptions, and to thus establish a common code. A common code may be used by experts in the field to communicate, exchange and compare results and to translate some of the results into common sense-based explanations that can be made widely available. In order to circulate new discoveries and highly specialized knowledge in medicine and to disseminate it to a larger community, accurate planning of consistent metaphors and analogies are of crucial help. Accurate metaphors and analogies come as a result of a skilled art and science; no metaphor or analogy can represent a specific topic within a highly specialized knowledge domain without having first undergone major processes of redefinition. This is precisely what will be explored in this chapter, the added value of both powerful and reliable conceptual tools in the medical field, such as metaphors and analogies, and a commonly shared code to make qualitative reasoning about medical information possible. To improve progress in research and medical care, everyone needs to establish a common language to work with and from. In terms of medical advice documentation, the use of a visual system, CTML, would be instrumental in providing and documenting information. This system can be understood by and thus connect researchers, health care professionals, and patients. PMID:12026124
Background The role of patient race in medicaldecision-making is heavily debated. While some evidence suggests that patient race can be used by physicians to predict disease risk and determine drug therapy, other studies document bias and stereotyping by physicians based on patient race. It is critical, then, to explore physicians' attitudes regarding the medical relevance of patient race. Methods We conducted a qualitative study in the United States using ten focus groups of physicians stratified by self-identified race (black or white) and led by race-concordant moderators. Physicians were presented with a medical vignette about a patient (whose race was unknown) with Type 2 diabetes and untreated hypertension, who was also a current smoker. Participants were first asked to discuss what medical information they would need to treat the patient. Then physicians were asked to explicitly discuss the importance of race to the hypothetical patient's treatment. To identify common themes, codes, key words and physician demographics were compiled into a comprehensive table that allowed for examination of similarities and differences by physician race. Common themes were identified using the software package NVivo (QSR International, v7). Results Forty self-identified black and 50 self-identified white physicians participated in the study. All physicians - regardless of their own race - believed that medical history, family history, and weight were important for making treatment decisions for the patient. However, black and white physicians reported differences in their views about the relevance of race. Several black physicians indicated that patient race is a central factor for choosing treatment options such as aggressive therapies, patient medication and understanding disease risk. Moreover, many black physicians considered patient race important to understand the patient's views, such as alternative medicine preferences and cultural beliefs about illness. However, few white physicians explicitly indicated that the patient's race was important over-and-above medical history. Instead, white physicians reported that the patient should be treated aggressively regardless of race. Conclusions This investigation adds to our understanding about how physicians in the United States consider race when treating patients, and sheds light on issues physicians face when deciding the importance of race in medicaldecision-making.
The purpose of this descriptive correlational study was to determine the extent that social factors, health beliefs, and attitudes influenced caregiver's decisions in home management with over-the-counter (OTC) medications. Home management decisions were ...
|Discussion of human motivation contrasts controlled and autonomous motivation, noting that autonomous motivation (self-determination) involves behaving with a sense of volition, agency, and choice. Suggests that medical students who learn in autonomy-supportive teaching and patient-centered environments, which have been associated with more…
Williams, Geoffrey C.; Saizow, Ronald B.; Ryan, Richard M.
The outsourcing movement is growing in all sectors of the economy, mainly in the Information Technology (IT) services area. Therefore, researches concerning the aspects related to IT outsourcing decisions are an important knowledge to be deeveloped. Revising the literature it was possible to verify the prevalence of six decisions aspects in IT outsourcing decisions. Some authors demonstrated that professionals in
Fuzzy Cognitive Maps (FCMs) have been used to design Decision Support Systems and particularly for medical informatics to\\u000a develop Intelligent Diagnosis Systems. Even though they have been successfully used in many different areas, there are situations\\u000a where incomplete and vague input information may present difficulty in reaching a decision. In this chapter the idea of using\\u000a the Case Based Reasoning
This study aimed to focus on medical knowledge representation and reasoning using the probabilistic and fuzzy influence processes, implemented in the semantic web, for decision support tasks. Bayesian belief networks (BBNs) and fuzzy cognitive maps (FCMs), as dynamic influence graphs, were applied to handle the task of medical knowledge formalization for decision support. In order to perform reasoning on these knowledge models, a general purpose reasoning engine, EYE, with the necessary plug-ins was developed in the semantic web. The two formal approaches constitute the proposed decision support system (DSS) aiming to recognize the appropriate guidelines of a medical problem, and to propose easily understandable course of actions to guide the practitioners. The urinary tract infection (UTI) problem was selected as the proof-of-concept example to examine the proposed formalization techniques implemented in the semantic web. The medical guidelines for UTI treatment were formalized into BBN and FCM knowledge models. To assess the formal models' performance, 55 patient cases were extracted from a database and analyzed. The results showed that the suggested approaches formalized medical knowledge efficiently in the semantic web, and gave a front-end decision on antibiotics' suggestion for UTI. PMID:23953959
Two of the patient's rights in a Uniform Act for the Terminally Ill should be a) the right to be treated if there is reasonable doubt of the patient's wishes until it becomes clear that the treatment is not beneficial and that the patient is indeed terminally ill, and b) the right not to be subjected to treatment with no medical benefit. A physician with appropriate supporting independent opinions would be the logical individual to whom the responsibility of protecting those rights should be given. This is particularly true when the patient is incapable of his or her own medicaldecisions and has left no instructions regarding his or her personal goals in medical care in the event of severe illness. Two cases and an analysis of power in medicaldecision-making illustrate these points. PMID:11651553
Koch, Kathryn A; Meyers, Bruce W; Sandroni, Stephen
Currently, the need for the recruitment and retention of qualified Under-Represented Minority (URM) students remains a pressing concern for U.S. medical schools. In response to this need, we analyzed admissions data at our medical school to determine which factors may positively or negatively influence the decision of an URM applicant to matriculate at our school, when compared to their White\\/Asian
Stacey J. Kadish; Michele M. Carlin; Karen Lawton; John A. Paraskos; Michele P. Pugnaire
Background: Older adults take multiple medications and are at high risk for adverse drug effects.Objective: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults.Methods: PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they
This study looks at the importance of refereed and nonrefereed publications in tenure and promotion decisions within 26 English speaking graduate colleges, faculties or schools of education in Canada. One hundred and thirty-nine administrators, within both master and doctoral degree-granting institutions, were polled. The first part of the questionnaire asked respondents to rate the importance of publication in 40 pre-listed
Background Genetic testing is increasingly used as a tool throughout the health care system. In 2011 the number of clinically available genetic tests is approaching 2,000, and wide variation exists between these tests in their sensitivity, specificity, and clinical implications, as well as the potential for discrimination based on the results. Discussion As health care systems increasingly implement electronic medical record systems (EMRs) they must carefully consider how to use information from this wide spectrum of genetic tests, with whom to share information, and how to provide decision support for clinicians to properly interpret the information. Although some characteristics of genetic tests overlap with other medical test results, there are reasons to make genetic test results widely available to health care providers and counterbalancing reasons to restrict access to these test results to honor patient preferences, and avoid distracting or confusing clinicians with irrelevant but complex information. Electronic medical records can facilitate and provide reasonable restrictions on access to genetic test results and deliver education and decision support tools to guide appropriate interpretation and use. Summary This paper will serve to review some of the key characteristics of genetic tests as they relate to design of access control and decision support of genetic test information in the EMR, emphasizing the clear need for health information technology (HIT) to be part of optimal implementation of genetic medicine, and the importance of understanding key characteristics of genetic tests when designing HIT applications.
Background Despite benefits of adherence, little is known about the degree to which patients will express their perceptions of medications as more or less important to take as prescribed. We determined the frequency with which Veteran patients would explicitly identify one of their medications as “most important” or “least important.” Findings We conducted a retrospective cohort study of patients from ambulatory clinics at VA Boston from April 2010-July 2011. Patients answered two questions: “Which one of your medicines, if any, do you think is the most important? (if none, please write ‘none’)” and “Which one of your medicines, if any, do you think is the least important? (if none, please write ‘none’).” We determined the prevalence of response categories for each question. Our cohort of 104 patients was predominantly male (95%), with a mean of 9 medications (SD 5.7). Regarding their most importantmedication, 41 patients (39%) identified one specific medication; 26 (25%) selected more than one; 21 (20%) wrote “none”; and 16 (15%) did not answer the question. For their least importantmedication, 31 Veterans (30%) chose one specific medication; two (2%) chose more than one; 51 (49%) wrote “none”; and 20 (19%) did not directly answer the question. Conclusions Thirty-five percent of patients did not identify a most importantmedication, and 68% did not identify a least importantmedication. Better understanding of how patients prioritize medications and how best to elicit this information will improve patient-provider communication, which may in turn lead to better adherence.
Should a patient be forced to accept a treatment, especially when suffering from a neurodegenerative disease? We argue that physicians, nurses and care givers should instead accept his or her choice in accordance with the principle that every patient is an autonomous person able to make a choice, even in case of declined cognition. Beside the legal obligation, we suggest a theoretical approach and focus on the practical impacts of the patient's decision. Our objective is to promote the value of ethical doubt and attentive listening to individual opinions, so as to improve the quality of the medical staff's work and reduce patients' distress when affected by fatal diseases. PMID:23398961
|Purpose: We examined race/ethnicity and cultural context within hypothetical end-of-life medicaldecision scenarios and its influence on patient-proxy agreement. Design and Methods: Family dyads consisting of an older adult and 1 family member, typically an adult child, responded to questions regarding the older adult's preferences for…
Schmid, Bettina; Allen, Rebecca S.; Haley, Philip P.; DeCoster, Jamie
In the context of a worldwide physician brain drain phenomenon, Lebanon has the highest emigration factor in the Middle East and North Africa. In this manuscript we aim to identify and develop a conceptual framework for the factors underlying the decisions of graduating Lebanese medical students to train abroad. We conducted two focus groups and seven semi-structured individual interviews with
Elie A. Akl; Nancy Maroun; Stella Major; Claude Afif; Bechara Chahoud; Jacques Choucair; Mazen Sakr; Holger J. Schünemann
|As a patient approaches the end of life, he or she faces a number of very difficult medicaldecisions. Allied health care professionals, including speech-language pathologists (SLPs) and occupational therapists (OTs), can be instrumental in assisting their patients to make advance care plans, although their traditional job descriptions do not…
There are a number of different quantitative models that can be used in a medical diagnostic decision support system (MDSS) including parametric methods (linear discriminant analysis or logistic regression), non-parametric models (K nearest neighbor, or kernel density) and several neural network models. The complexity of the diagnostic task is thought to be one of the prime determinants of model selection.
|This article reviews evidence on the treatment and comorbidity of psychiatric disorders with the purpose of suggesting odds that a child with behavioral disorder may indeed have a disorder that is responsive to psychopharmacologic treatment. Merging the medical and behavioral models is suggested as critical to special education decisions.…
Ability to make decisions about medical treatment is compromised in significant numbers of people with neurological and psychiatric illness, and this incapacity frequently corresponds with compromised neuropsychological function. Although cognitive deficits occur often in people with multiple sclerosis (MS), no research has studied decisional capacity in that disease. The present investigation examined ability to understand treatment disclosures, which is a
Michael R. Basso; Philip J. Candilis; Jay Johnson; Courtney Ghormley; Dennis R. Combs; Taeh Ward
This thesis examines stay/leave decisions of Medical Service Corps (MSC) Officers in pay grades 0-1 through 0-4. Reasons why they choose to stay or leave the Navy and their attitudes toward continued service are identified and explored. Since few studies ...
|Objective: The authors compared the importance of items related to professional behavior among medical students rotating through their psychiatry clerkship, psychiatry residents, and attending psychiatrists. Method: The authors sent an electronic survey with 43 items (rated on the scale 1: Not at All Important; to 5: Very Important) to medical…
Morreale, Mary K.; Balon, Richard; Arfken, Cynthia L.
Yeasts are being increasingly identified as important organisms in human infections. Adhesive interactions between yeasts and bacteria may contribute to yeast retention at body sites. Methods for studying adhesive interactions between bacterial strains are well known, and range from simple macroscopic methods to flow chamber systems with complex image analysis capabilities. The adhesive interactions between bacteria and yeasts have been
Kevin W. Millsap; Henny C. van der Mei; Rolf Bos; Henk J. Busscher
Of more than 500 arboviruses recognized worldwide, 5 were first isolated in Canada and 58 were first isolated in the United States. Six of these viruses are human pathogens: western equine encephalitis (WEE) and eastern equine encephalitis (EEE) viruses (family Togaviridae, genus Alphavirus), St. Louis encephalitis (SLE) and Powassan (POW) viruses (Flaviviridae, Flavivirus), LaCrosse (LAC) virus (Bunyaviridae, Bunyavirus), and Colorado tick fever (CTF) virus (Reoviridae, Coltivirus). Their scientific histories, geographic distributions, virology, epidemiology, vectors, vertebrate hosts, transmission, pathogenesis, clinical and differential diagnoses, control, treatment, and laboratory diagnosis are reviewed. In addition, mention is made of the Venezuelan equine encephalitis (VEE) complex viruses (family Togaviridae, genus Alphavirus), which periodically cause human and equine disease in North America. WEE, EEE, and SLE viruses are transmitted by mosquitoes between birds; POW and CTF viruses, between wild mammals by ticks; LAC virus, between small mammals by mosquitoes; and VEE viruses, between small or large mammals by mosquitoes. Human infections are tangential to the natural cycle. Such infections range from rare to focal but are relatively frequent where they occur. Epidemics of WEE, EEE, VEE, and SLE viruses have been recorded at periodic intervals, but prevalence of infections with LAC and CTF viruses typically are constant, related to the degree of exposure to infected vectors. Infections with POW virus appear to be rare. Adequate diagnostic tools are available, but treatment is mainly supportive, and greater efforts at educating the public and the medical community are suggested if infections are to be prevented.
Medical devices work in the presence of significant electromagnetic interference. Therefore, interference stability is a very important parameter of medical devices and systems because it contributes substantially to safety and reliability requirements . Electromagnetic compatibility (EMC) is determined by the requirements of interference emission and interference stability. All electrical devices are routinely tested for interference emission, whereas tests of medical
B. N. Faizulaev; K. S. Oraevskii; I. N. Porfir'ev; V. V. Logachev; I. P. Gorshkova
Illness scripts are knowledge structures composed of consequences, enabling conditions, and faults. The effects of illness script components--consequences and enabling conditions--and physician factors on referral decisions for gastrointestinal disorders were investigated. The hypothesis that consequences and enabling conditions increase the…
van Schaik, Paul; Flynn, Darren; van Wersch, Anna; Douglass, Andrew; Cann, Paul
Our understanding of the causative agents of fungal diseases has changed considerably in recent years due to molecular studies\\u000a that compare DNA across a wide range of fungi, including human and animal pathogens. In many cases, what had once been understood\\u000a as traditional species were found to be species complexes. Importantly, members of such complexes may differ in pathogenicity\\u000a and
Teun Boekhout; Cécile Gueidan; Sybren de Hoog; Rob Samson; Janos Varga; Grit Walther
Decisions about breast reconstruction after mastectomy are some of the most difficult decisions a breast cancer patient makes. To make a good decision, the patient should have adequate knowledge of specific facts related to the decision, and the treatment chosen should be consistent with the patient's personal preferences or goals. We sought to identify the most important facts and goals for decisions about breast reconstruction after mastectomy, and to compare patients' and providers' perspectives. We conducted a cross-sectional survey of breast cancer survivors and providers. Participants rated and ranked the importance of facts and goals/concerns related to breast reconstruction after mastectomy. We compared patients' and providers' rankings using chi2 tests and compared ratings using t-tests. About 21 patients and 20 providers participated. Facts: Providers were more concerned about the impact of radiation on the success of the reconstruction than patients (60% vs. 24%, 95% CI of the difference: -64, -8). Thirty percent of providers placed the fact that women who do not have reconstruction are equally satisfied as women who have reconstruction in the top 3, whereas almost no patients did (30% vs. 5%, 95% CI: -47, -3). For all 3 of the facts about immediate versus delayed reconstruction, women placed a higher priority on these facts than providers did. Goals: Patients placed greater importance on avoiding use of a prosthesis (33% vs. 0%, 95% CI of the difference: 13, 54). There was a trend toward less patient concern about "looking natural without clothes" compared to providers (24% vs. 40%, 95% CI of the difference: -12, 44). Significant variability exists among patients and between patients and providers, with respect to the most important facts and goals to guide decision making about reconstruction. Providers should ensure that women understand that reconstruction can be performed immediately or delayed, as well as the likelihood and type of complications. Surgeons should ask each woman which goals and concerns are most important to her. Specifically, they should inquire as to how women feel about using a prosthesis, and how they feel about their appearance with and without clothes. PMID:20395809
\\u000a Background Despite the popularity of medical student-run health clinics among U.S. medical schools, there is no information about how\\u000a many clinics exist, how many students volunteer there, or how many patients they see and what services they offer.\\u000a \\u000a \\u000a \\u000a Objective We describe, for the first time, the prevalence and operation of medical student-run health clinics nationwide.\\u000a \\u000a \\u000a \\u000a Design and participants A web-based survey was sent
This paper identifies and discusses some of the important consequences of nuclear power plant unavailability, and quantifies a number of technical measures of loss of benefits that may help the Nuclear Regulatory Commission make decisions involving nuclear power plant licensing and operation. The loss-of-benefits analysis presented here is based on the results of a series of case studies developed by Argonne National Laboratory in cooperation with four electric utilities on hypothetical nuclear plant shutdowns.
BACKGROUND: In North America, acute respiratory infections are the main reason for doctors' visits in primary care. Family physicians and their patients overuse antibiotics for treating acute respiratory infections. In a pilot clustered randomized trial, we showed that DECISION+, a continuing medical education program in shared decision making, has the potential to reduce the overuse of antibiotics for treating acute
Anne-Sophie Allaire; Michel Labrecque; Anik Giguère; Marie-Pierre Gagnon; Jeremy Grimshaw
This paper describes the development and use of the Medication Recommendation Tracking Form (MRTF), a novel method for capturing physician prescribing behavior and clinical decision making. The Bipolar Trials Network developed and implemented the MRTF in a comparative effectiveness study for bipolar disorder (LiTMUS). The MRTF was used to assess the frequency, types, and reasons for medication adjustments. Changes in treatment were operationalized by the metric Necessary Clinical Adjustments (NCA), defined as medication adjustments to reduce symptoms, optimize treatment response and functioning, or to address intolerable side effects. Randomized treatment groups did not differ in rates of NCAs, however, responders had significantly fewer NCAs than non-responders. Patients who had more NCAs during their previous visit had significantly lower odds of responding at the current visit. For each one-unit increase in previous CGI-BP depression score and CGI-BP overall severity score, patients had an increased NCA rate of 13% and 15%, respectively at the present visit. Ten-unit increases in previous Montgomery Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS) scores resulted in an 18% and 14% increase in rates of NCAs, respectively. Patients with fewer NCAs had increased quality of life and decreased functional impairment. The MRTF standardizes the reporting and rationale for medication adjustments and provides an innovative metric for clinical effectiveness. As the first tool in psychiatry to track the types and reasons for medication changes, it has important implications for training new clinicians and examining clinical decision making. (ClinicalTrials.gov number NCT00667745). PMID:23911057
Reilly-Harrington, Noreen A; Sylvia, Louisa G; Leon, Andrew C; Shesler, Leah W; Ketter, Terence A; Bowden, Charles L; Calabrese, Joseph R; Friedman, Edward S; Ostacher, Michael J; Iosifescu, Dan V; Rabideau, Dustin J; Thase, Michael E; Nierenberg, Andrew A
Psychiatric disorders frequently make the patient unable to perform their work. It is estimated that psychiatric disorders are the third most frequent reason for an expert's decision concerning long-term inability to work justifying the granting of a disability pension. Unfortunately, not all patients are certified positively, i.e. are granted disability pension or receive disability benefits in the expected amount; usually, they are lower than those they applied for. The paper discusses the premises applied by the Social Insurance Institution (ZUS) physicians and court appointed experts in their examination of patients applying for disability benefits. Some patients are positively certified already at the time of the initial contact. Their mode of behavior, functioning and patterns of speech leave no doubt as to the significant exacerbation of their mental disturbances. Another group of patients manifests situational "exacerbation" connected with the stressful nature of a meeting with an expert physician. In such cases, the patient's medical records are of great importance. Evaluation of medical records takes into account regular and systematic character of treatment, as well as the kind of pharmacotherapy applied in the treatment. The patient's discontinuation of treatment just after having been granted disability benefits and restarting it a short time before check-up examination is regarded rather critically. Rare appointments taking place once or twice a year are not recognized as corresponding with the existence of intense and debilitating mental disorders. Duration of treatment before applying for disability pension is also evaluated. The author discusses particular cases in the context of ethical and deontological principles. PMID:17571520
Group Decision Support Systems (GDSS) are defined and discussed. A GDSS model developed by the author is reviewed in depth for communication of the concepts of GDSS. The model's components are related to health care applications. Questions about unique requirements and level of sophistication in health care applications are explored. What are the differences? What is needed in GDSS software? How do implementation strategies differ? The purpose of this paper is to define and discuss the uniqueness and level of sophistication of GDSS applications in health care. The information requirements and level of information abstraction are the major forces considered in the design of specific medical GDSSs. Data for the GDSS and queries originate both internally and externally to the system. Raw data may be in image form and require extensive analysis by the decision makers for information to be extracted from the raw data. Efforts also are made to relate financial and medical data for better business decisions. This integration often has limited success. Additionally, financial data represent multiple sources and present concerns of validity and reliability. In medical diagnoses the knowledge bases are large and contain thousands of rules. Treatment planning and progress reporting rely on medical records that contain thousands of information items and that often require interpretation by an expert. These information attributes go beyond qualitative versus quantitative definitions and are the author's basis for the analysis presented in this paper. PMID:2132042
One promising way to increase the classification accuracy of medicaldecision support systems is to implement heuristic combinations of pattern recognition and artificial intelligence tools. A parallel between "cognition" model and differential diagnostic task is sketched accentuating the aggregation of activating and restraining inputs and corresponding PRO and CON evidence in medicine. On the basis of this paradigm a trainable model of a fuzzy neuron is proposed which resembles some elements from the physician's decision process. An example from aviation medicine is presented which demonstrates the enhanced performance. PMID:8306621
Objectives To examine the current status of hospital information systems (HIS), analyze the effects of Electronic Medical Records (EMR) and Clinical Decision Support Systems (CDSS) have upon hospital performance, and examine how management issues change over time according to various growth stages. Methods Data taken from the 2010 survey on the HIS status and management issues for 44 tertiary hospitals and 2009 survey on hospital performance appraisal were used. A chi-square test was used to analyze the association between the EMR and CDSS characteristics. A t-test was used to analyze the effects of EMR and CDSS on hospital performance. Results Hospital size and top management support were significantly associated with the adoption of EMR. Unlike the EMR results, however, only the standardization characteristic was significantly associated with CDSS adoption. Both EMR and CDSS were associated with the improvement of hospital performance. The EMR adoption rates and outsourcing consistently increased as the growth stage increased. The CDSS, Knowledge Management System, standardization, and user training adoption rates for Stage 3 hospitals were higher than those found for Stage 2 hospitals. Conclusions Both EMR and CDSS influenced the improvement of hospital performance. As hospitals advanced to Stage 3, i.e. have more experience with information systems, they adopted EMRs and realized the importance of each management issue.
Dematiaceous fungi include a large group of organisms that are darkly pigmented (dark brown, olivaceous, or black). In most cases the pigment is melanin, and specifically, dihydroxynaphthalene melanin. The diseases produced include chromoblastomycosis, eumycotic mycetoma, and phaeohyphomycosis. Phaeohyphomycosis is a new classification for a diverse group of previously known entities grouped together on the basis of finding dematiaceous hyphal and/or yeast-like forms in tissue; tissue involvement may be superficial, cutaneous and corneal, subcutaneous, or systemic. Identification of these fungi is based mostly upon morphology. Important structures include annellides (Phaeoannellomyces, Exophiala), phialides (Phialophora, Wangiella), adelophialides (Phialemonium without collarettes, Lecythophora with collarettes), differentiation of conidiophores (Xylohypha versus Cladosporium) and conidial hilum, septation and germination (Bipolaris, Drechslera, Exserohilum). Useful laboratory tests include the 12% gelatin test (controversial), nitrate assimilation (W. dermatitidis is negative, most other species are positive), and determination of temperature maxima (especially 37 degrees C for E. jeanselmei, 40 degrees C for W. dermatitidis and B. spicifera, 42 degrees C for X. bantiana, and 45 degrees C for Dactylaria constricta var. gallopava and Scedosporium inflatum). PMID:1922184
SCIENCE HAS MANY Western and Eastern historical roots. All of these contributed to the body of academic literature. One of the most important aspects of scientific progress is educational institutions, including hospitals, schools, and libraries. Some of these institutions may offer an identity for a city, as well as contribute to its development. Süleymaniye Külliyesi is one such institution. Süleymaniye Külliyesi, established in the 16th century, contains many centers, including a mosque, surrounded by a hospital, school of medicine, central pharmacy, and library. It once served both the Ottoman Empire and the Turkish Republic. The school of medicine of this complex was the first school of medicine in the Ottoman period that functioned in coordination with the hospital and central pharmacy. The library contains many rare books and manuscripts. Currently, it is one of the richest centers in the field of oriental studies. We conclude that Süleymaniye Külliyesi, with its health-related elements and library, contributed to the development and progress of science and deserves to be cited in the literature of the Western world. PMID:16883182
Background Despite the popularity of medical student-run health clinics among U.S. medical schools, there is no information about how many clinics exist, how many students volunteer there, or how many patients they see and what services they offer. Objective We describe, for the first time, the prevalence and operation of medical student-run health clinics nationwide. Design and participants A web-based survey was sent to all 124 Association of American Medical Colleges allopathic schools in the 50 states. Results Ninety-four schools responded (76%); 49 schools had at least 1 student-run clinic (52%). Fifty-nine student-run clinics provided detailed data on their operation. The average clinic had 16 student volunteers a week, and most incorporated preclinical students (56/59, 93%). Nationally, clinics reported more than 36,000 annual patient–physician visits, in addition to more nonvisit encounters. Patients were predominantly minority: 31% Hispanic; 31% Black/African American; 25% White; 11% Asian; and 3% Native American or other. Most student-run health clinics had resources both to treat acute illness and also to manage chronic conditions. Clinics were most often funded by private grants (42/59, 71%); among 27 clinics disclosing finances, a median annual operating budget of $12,000 was reported. Conclusions Medical student-run health clinics offer myriad services to disadvantaged patients and are also a notable phenomenon in medical education. Wider considerations of community health and medical education should not neglect the local role of a student-run health clinic.
I examine the importance of physicians in the process by which patients receive either trade-name or generic drugs. Using a dataset on physicians, their patients, and the multisource drugs prescribed, I find that almost all physicians prescribe both types of drugs to their patients, but some physicians are more likely to prescribe generic drugs while other physicians are more likely to prescribe trade-name drugs. Very little of the prescription decision can be explained by observable characteristics of individual patients, but all of the evidence indicates that physicians are indeed an important agent in determining whether patients receive either trade-name or generic drugs. PMID:10182437
Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially
A survey of McMaster University's first six medical classes (1972-1977) has shown that neither completion of the science courses that are usually required for admission to other medical schools nor achievement of high grades in premedical studies has an important impact on graduates' perceptions of the medical curriculum or on their evaluation of their preparation for the first year of postgraduate training in comparison to other trainees. No influence of either premedical science background or grade point average was detected on career choices in relation to field of medicine entered, level of specialization, location and type of practice, or on factors influencing these choices. PMID:6843392
The aim of the present project was the development of an integrated computer-based system supporting training in medical and administrative decision making in the Emergency Department. The system comprises of, first, a module supporting on-line acquaintance with Emergency Medical Guidelines, second, a vital-signs monitoring and processing module, and finally an administrative module organizing the most relevant facts about a patient's health status in compliance with the ASTM E2369-0 Standard Specification for Continuity of Care Record, in order to be employed after discharge from the Emergency Care to a hospital ward or to homecare. PMID:17945725
Spyropoulos, B; Tzavaras, A; Botsivaly, M; Moschidis, M; Koutsourakis, K
We examined male partners’ influence on the decision to seek medical help for infertility using from the National Survey of Fertility Barriers. Building upon an existing help-seeking framework, we incorporated characteristics of both partners from 219 heterosexual couples who had ever perceived a fertility problem. In logistic regression analyses, we found an association between couple-level attitudes and medical help-seeking even when other predisposing and enabling conditions existed. Overall, the findings highlight that both partners contribute to the infertility help-seeking process, and that different factors may play a role in different stages of help-seeking. Studies of infertility help-seeking need to be more inclusive of the context that these decisions are embedded within to better understand service use.
Background Many critical treatment decisions are based on the medical history of patients with an acute coronary syndrome (ACS). Discrepancies between the medical history documented by a health professional and the patient's own report may therefore have important health consequences. Methods Medical histories of 117 patients with an ACS were documented. A questionnaire assessing the patient's health history was then completed by 62 eligible patients. Information about 13 health conditions with relevance to ACS management was obtained from the questionnaire and the medical record. Concordance between these two sources and reasons for discordance were identified. Results There was significant variation in agreement, from very poor in angina (kappa < 0) to almost perfect in diabetes (kappa = 0.94). Agreement was substantial in cerebrovascular accident (kappa = 0.76) and hypertension (kappa = 0.73); moderate in cocaine use (kappa = 0.54), smoking (kappa = 0.46), kidney disease (kappa = 0.52) and congestive heart failure (kappa = 0.54); and fair in arrhythmia (kappa = 0.37), myocardial infarction (kappa = 0.31), other cardiovascular diseases (kappa = 0.37) and bronchitis/pneumonia (kappa = 0.31). The odds of agreement was 42% higher among individuals with at least some college education (OR = 1.42; 95% CI, 1.00 - 2.01, p = 0.053). Listing of a condition in medical record but not in the questionnaire was a common cause of discordance. Conclusion Discrepancies in aspects of the medical history may have important effects on the care of ACS patients. Future research focused on identifying the most effective and efficient means to obtain accurate health information may improve ACS patient care quality and safety.
This study examines community living , independent seniors' perceptions and views of preferences for surrogate decision makers, life-sustaining medical treatment, and advance health care directives. Data were collected through in-depth personal interviews with 26 seniors living in the Hamilton-Wentworth area of Ontario. This study looked for differences in these perceptions by socio-demographic background characteristics. Using case vignettes involving elderly patients
An ‘on-line’ evidence-based decision support tool called Diagnostic Imaging Pathways (DIP) was developed at Royal Perth Hospital (RPH) to assist clinicians request the most appropriate examinations to achieve a diagnosis. DIP is accessed from the ‘desk-top’ and the Internet (www.imagingpathways.health.wa.gov.au). Clinicians at RPH are regularly alerted to DIP recommendations at the ‘Grand Round’, in medical newsletters and in the orientation
Phillip J Bairstow; R Mendelson; Jennifer Persaud; L Nguyen
Patients with chronic migraine developing medication-overuse headache (MOH) show dependency-like behaviors such as loss of control over analgesics despite adverse consequences on headaches, high rates of relapse after withdrawal from symptomatic medications, and compromised social functioning. Neuroimaging research suggests a common pathophysiology between substance-use disorders and MOH, which involves functional alterations in fronto-striatal networks, particularly in the orbitofrontal region of prefrontal cortex. These findings could explain the impaired decision-making observed in substance-use disorders. We hypothesize that MOH could share fronto-striatal circuit dysfunction and relative decision-making deficit with addiction. We further examine whether this deficit is a persistent cognitive trait or a reversible consequence of medication overuse. This study shows a dataset of 50 patients with MOH before the detoxification. All patients underwent a complete neurological and psychiatric examination. Psychiatric examination consisted of a clinical interview, Structured Clinical Interview for DSM-IV TR Axis II Personality Disorders, Anxiety and Depression Hamilton Scales, Severity of Dependence Scale. The neurological examination included the migraine disability assessment questionnaire. Neuropsychological assessment of fronto-striatal circuits was investigated using the Iowa gambling task (IGT). Twenty patients monitored for any relapse into medication overuse had 12 months of follow-up. Our sample, characterized by high rates of disability and dependency-like behaviors, exhibited a deficit in IGT performance, indicating an overall impairment in decision-making. All the 20 patients showed neurological and psychiatric improvement at 12-month follow-up, notwithstanding the overuse relapse, but a persistent IGT deficit was found. To our knowledge this is the first study that assesses this cognitive function in patients with MOH. Medication-overuse headache seems to share a persistent decision-making deficit with substance abuse that confirms the orbitofrontal cortex hypometabolism described in literature from a neuropsychological perspective. Looking at these shared neurocognitive features, our results suggest that MOH could belong to the addiction spectrum. Fronto-striatal dysfunction could be a premorbid psychobiological condition of vulnerability explaining the clinical onset of medication overuse and recurrent relapses. We propose that IGT could be used to identify chronic migraine patients with higher risk for medication overuse and relapse. PMID:22644192
Introduction The liability crisis may affect residency graduates' practice decisions, yet structured liability education during residency is still inadequate. The objective of this study was to determine the influence of medical liability on practice decisions and to evaluate the adequacy of current medical liability curricula. Methods All fourth-year residents (n??=??1274) in 264 Accreditation Council for Graduate Medical Education–accredited allopathic and 25 osteopathic US obstetrics and gynecology residency training programs were asked to participate in a survey about postgraduate plans and formal education during residency regarding liability issues in 2006. Programs were identified by the Council on Resident Education in Obstetrics and Gynecology directory and the American College of Osteopathic Obstetricians and Gynecologists residency program registry. Outcome measures were the reported influence of liability/malpractice concerns on postresidency practice decision making and the incidence of formal education in liability/malpractice issues during residency. Results A total of 506 of 1274 respondents (39.7%) returned surveys. Women were more likely than men to report “region of the country” (P??=??.02) and “paid malpractice insurance as a salaried employee” (P??=??.03) as a major influence. Of the respondents, 123 (24.3%) planned fellowship training, and 229 (45.3%) were considering limiting practice. More than 20% had been named in a lawsuit. Respondents cited Pennsylvania, Florida, and New York as locations to avoid. In response to questions about medical liability education, 54.3% reported formal education on risk management, and 65.2% indicated they had not received training on “next steps” after a lawsuit. Discussion Residents identify liability-related issues as major influences when making choices about practice after training. Structured education on matters of medical liability during residency is still inadequate.
Blanchard, May Hsieh; Ramsey, Patrick S.; Gala, Rajiv B.; Bannerman, Cynthia Gyamfi; Srinivas, Sindhu K.; Hernandez-Rey, Armando E.
HyperCard presents an uncoventional instructional environment for educators and students, in that it is nonlinear, nonsequential, and it provides innumerable choices of learning paths to learners. The danger of this environment is that it may frustrate learners whose cognitive and learning styles do not match this environment. Leaners who prefer guided learning rather than independent exploration may become distracted or disoriented by this environment, lost in “hyperspace.” In the context of medical education, these ill-matched styles may produce some physicians who have not mastered skills essential to the practice of medicine. The authors have sought to develop a HyperCard learning environment consisting of related programs that teach medicaldecision making. The environment allows total learner control until the learner demonstrates a need for guidance in order to achieve the essential objectives of the program. A discussion follows of the implications of hypermedia for instructional design and medical education.
Background Clinicians view the accuracy of test results and the turnaround time as the two most important service aspects of the clinical\\u000a microbiology laboratory. Because of the time needed for the culturing of infectious agents, final hardcopy culture results\\u000a will often be available too late to have a significant impact on early antimicrobial therapy decisions, vital in infectious\\u000a disease management. The
Marjan J Bruins; Gijs JHM Ruijs; Maurice JHM Wolfhagen; Peter Bloembergen; Jos ECM Aarts
In psychiatry, and in treating people with a diagnosis of schizophrenia in particular, there are obstacles to achieving concordant, shared decision making and in building a co-operative therapeutic alliance where mutual honesty is the norm. Studies of people with a diagnosis of schizophrenia have revealed critical views of medical authority, particularly over the issue of enforced compliance with antipsychotic medication. Psychiatrists are known to place particular value on such medication. This qualitative study reports the views of 21 general adult psychiatrists working in UK about their experiences of consultations involving discussion of antipsychotic medication. Interviewees reported a general commitment to achieving concordant relationships with patients and described a number of strategies they used to promote this. In this respect, their self-perception differs from the picture of authoritarian practice painted by critics of psychiatry, and by some studies reporting patients' views. Interviewees also described obstacles to achieving concordance, including adverse judgements of patients' competence and honesty about their medication use. Explaining the adverse effects of medication was perceived to discourage some patients from accepting this treatment. Moments of strategic dishonesty were reported. Psychiatrists perceived that trust could be damaged by episodes of coercion, or by patients' perception of coercive powers. We conclude that a self-perception of patient-centredness may not preclude psychiatrists from fulfilling a social control function. PMID:16343722
Seale, Clive; Chaplin, Robert; Lelliott, Paul; Quirk, Alan
Waiting for medical test results that signal physical harm can be a stressful and potentially psychologically harmful experience. Despite this, interventionists and physicians often use this wait time to deliver behavior change messages and other important information about the test, possible results and its implications. This study examined how “bracing” for a medical test result impacts cognitive processing, as well
BackgroundAutomated clinical decision support has shown promise in reducing medication errors; however, clinicians often do not comply with alerts. Because renal insufficiency is a common source of medication errors, the authors studied a trial of alerts designed to reduce inpatient administration of medications contraindicated due to renal insufficiency.MethodsA minimum safe creatinine clearance was established for each inpatient formulary medication. Alerts
William L. Galanter; Robert J. Didomenico; Audrius Polikaitis
IntroductionInappropriate medication among elderly people increases the risk of adverse drug–drug interactions, drug-related falls and hospital admissions. In order to prevent these effects it is necessary to obtain a profile of the patients’ medication. A personal digital assistant (PDA) can be used as a medicaldecision support system (MDSS) to obtain a profile of the patients’ medication and to check
Pauline E. Johansson; Göran I. Petersson; Gunilla C. Nilsson
Parasarcophaga (Liopygia) ruficornis is a well-known flesh fly species of medicalimportance, both as a myiasis-producing agent and fly seen in a forensic entomology context. This study performed a comprehensive literature review of this fly species, dealing with morphology, bionomics and medical involvement. Important characteristics used to identify P. ruficornis have been provided for both its third instar and adult for identification purpose in the future. PMID:23959482
Suwannayod, S; Sanit, S; Sukontason, K; Sukontason, K L
Memory awareness in early Alzheimer's disease (AD) influences capacity to provide informed consent for a memory treatment. This study investigated the extent to which aspects of memory awareness influence everyday decision-making capacity about medication management in AD. 42 participants with mild AD and 50 healthy elders underwent clinical ratings of memory awareness, metamemory testing, and an interview of everyday decision-making capacity regarding medication management. 45% of AD subjects were classified as aware (AAD) and 55% as unaware (UAD) based on clinical ratings and supported by metamemory testing (P = .015). Capacity was impaired in each of the AD groups as compared to the healthy elders F(2, 67) = 17.63, UAD, P < .01; AAD, P = .01). Within the AD group, capacity correlated selectively with awareness as measured with clinical ratings (r = ?.41, P = .007) but not objective metamemory testing (r = ?.10, P = .60 ). Appreciation scores were lower in UAD as compared with AAD F(1,35) = 8.36, P = .007. Unawareness of memory loss should heighten clinicians' concern about everyday decision-making capacity in AD.
Cosentino, Stephanie; Metcalfe, Janet; Cary, Mark S.; De Leon, Jessica; Karlawish, Jason
Background Religious and spiritual (R/S) beliefs often affect patients' health care decisions, particularly with regards care at the end of life (EOL). Furthermore, patients desire more R/S involvement by the medical community however; physicians typically do not incorporate R/S assessment into medical interviews with patients. The effects of physicians' R/S beliefs on willingness to participate in controversial clinical practices such as medical abortions and physician assisted suicide has been evaluated, but how a physicians' R/S beliefs may affect other medicaldecision-making is unclear. Methods Using SurveyMonkey, an online survey tool, we surveyed 1972 members of the International Gynecologic Oncologists Society and the Society of Gynecologic Oncologists to determine the R/S characteristics of gynecologic oncologists and whether their R/S beliefs affected their clinical practice. Demographics, religiosity and spirituality data were collected. Physicians were also asked to evaluate 5 complex case scenarios. Results Two hundred seventy-three (14%) physicians responded. Sixty percent “agreed” or “somewhat agreed” that their R/S beliefs were a source of personal comfort. Forty-five percent reported that their R/S beliefs (“sometimes,” “frequently,” or “always”) play a role in the medical options they offered patients, but only 34% “frequently” or “always” take a R/S history from patients. Interestingly, 90% reported that they consider patients' R/S beliefs when discussing EOL issues. Responses to case scenarios largely differed by years of experience although age and R/S beliefs also had influence. Conclusions Our results suggest that gynecologic oncologists' R/S beliefs may affect patient care but that the majority of physicians fail to take a R/S history from their patients. More work needs to be done in order to evaluate possible barriers that prevent physicians from taking a spiritual history and engaging in discussions over these matters with patients.
Ramondetta, Lois; Brown, Alaina; Richardson, Gwyn; Urbauer, Diana; Thaker, Premal H.; Koenig, Harold G.; Gano, Jacalyn B.; Sun, Charlotte
This is the second article in a series of three that examines the legal role of medical professionals in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity. This article considers the position in Queensland, including the parens patriae jurisdiction of the Supreme Court. A review of the law in this State reveals that medical professionals play significant legal roles in these decisions. However, the law is problematic in a number of respects and this is likely to impede medical professionals' legal knowledge in this area. The article examines the level of training medical professionals receive on issues such as advance health directives and substitute decision-making, and the available empirical evidence as to the state of medical professionals' knowledge of the law at the end of life. It concludes that there are gaps in legal knowledge and that law reform is needed in Queensland. PMID:21528738
A pertinent, legible and complete medical record facilitates good patient care. The recording of the symptoms, signs and lab findings which are relevant to a patient's condition contributes importantly to the medical record. The consideration and documentation of other disease states known to be related to the patient's primary illness provide further enhancement. We propose that developing sets of disease-specific core elements which a physician may want to document in the medical record can have many benefits. We hypothesize that for a given disease, terms with high importance (TI) and frequency (TF) in the DX-plain, QMR and Iliad knowledge bases (KBs) are terms which are used commonly in the medical record, and may be, in fact, terms which physicians would find useful to document. A study was undertaken to validate ten such sets of disease-specific core elements. For each of ten prevalent diseases, high TI and TF terms from the three KBs mentioned were pooled to derive the set of core elements. For each disease, all patient records (range 385 to 16,972) from a computerized ambulatory medical record database were searched to document the actual use by physicians of each of these core elements. A significant percentage (range 50 to 86%) of each set of core elements was confirmed as being used by the physicians. In addition, all medical concepts from a selection of full text records were identified, and an average of 65% of the concepts were found to be core elements.(ABSTRACT TRUNCATED AT 250 WORDS)
Abstract Objectives Despite substantial evidence supporting the efficacy of stimulant medication for children with attention-deficit/hyperactivity disorder (ADHD), adherence to stimulant treatment is often suboptimal. Applying social/cognitive theories to understanding and assessing parent attitudes toward initiating medication may provide insight into factors influencing parent decisions to follow ADHD treatment recommendations. This report describes results from formative research that used focus groups to obtain parent input to guide development of a provider-delivered intervention to improve adherence to stimulants. Methods Participants were caregivers of children with ADHD who were given a stimulant treatment recommendation. Focus groups were recorded and transcribed verbatim. Data were analyzed by inductive, grounded theory methods as well as a deductive analytic strategy using an adapted version of the Unified Theory of Behavior Change to organize and understand parent accounts. Results Five groups were conducted with 27 parents (mean child age=9.35 years; standard deviation [SD]=2.00), mean time since diagnosis=3.33 years (SD=2.47). Most parents (81.5%) had pursued stimulant treatment. Inductive analysis revealed 17 attitudes facilitating adherence and 25 barriers. Facilitators included parent beliefs that medication treatment resulted in multiple functional gains and that treatment was imperative for their children's safety. Barriers included fears of personality changes and medication side effects. Complex patterns of parent adherence to medication regimens were also identified, as well as preferences for psychiatrists who were diagnostically expert, gave psychoeducation using multiple modalities, and used a chronic illness metaphor to explain ADHD. Theory-based analyses revealed conflicting expectancies about treatment risks and benefits, significant family pressures to avoid medication, guilt and concern that their children required medication, and distorted ideas about treatment risks. Parents, however, took pride in successfully pursuing efforts to manage their child behaviorally and to avoid medication when possible. Conclusions Focus group data identified social, cognitive, and affective influences on treatment decision making. Results support prior research comparing family/social functioning, physician characteristics, and adherence. Findings suggest that parent attitudes to psychiatric care need to be assessed comprehensively at initial evaluation to aid the development of psychoeducational messages, and a more careful consideration about how parents interpret and respond to adherence-related questioning.
A software system was designed whose aim is to support everyday scientific research of physicians in different fields of medicine. DREAM is a shell-like tool which can be customized embedding in it the desirable structure of a particular medical problem. Various basic statistical analyses are provided along with the decision support capabilities. The decision aid is proposed in two steps--feature selection and classifier design. Genetic algorithm is implemented as the feature selection procedure. The classifier design option includes crisp and fuzzy k-Nearest Neighbors rule and a two-level classification scheme based on majority rule on the votes of several first-level k-Nearest Neighbors classifiers. The system's performance is illustrated with a database from aviation medicine. PMID:8370280
OBJECTIVE To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency. DESIGN Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information. RESULTS The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units-relative risk 1.2 (1.0, 1.4). CONCLUSIONS Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions. Trial Registration: http://clinicaltrials.gov Identifier: NCT00599209. PMID:19390107
Field, Terry S; Rochon, Paula; Lee, Monica; Gavendo, Linda; Baril, Joann L; Gurwitz, Jerry H
Bayesian inference in medicaldecision making is a concept that has a long history with 3 essential developments: 1) the recognition of the need for data (demonstrable scientific evidence), 2) the development of probability, and 3) the development of inverse probability. Beginning with the demonstrative evidence of the physician's sign, continuing through the development of probability theory based on considerations of games of chance, and ending with the work of Jakob Bernoulli, Laplace, and others, we will examine how Bayesian inference developed. PMID:22287536
This essay illustrates what the Chinese family-based and harmony-oriented model of medicaldecision making is like as well as how it differs from the modern Western individual-based and autonomy-oriented model in health care practice. The essay discloses the roots of the Chinese model in the Confucian account of the family and the Confucian view of harmony. By responding to a series of questions posed to the Chinese model by modern Western scholars in terms of the basic individualist concerns and values embedded in the modern Western model, we conclude that the Chinese people have justifiable reasons to continue to apply the Chinese model to their contemporary health care and medical practice. PMID:20855426
Ability to make decisions about medical treatment is compromised in significant numbers of people with neurological and psychiatric illness, and this incapacity frequently corresponds with compromised neuropsychological function. Although cognitive deficits occur often in people with multiple sclerosis (MS), no research has studied decisional capacity in that disease. The present investigation examined ability to understand treatment disclosures, which is a core component of decisional capacity, in 36 people with MS and 16 normal controls. MS patients with diminished neuropsychological function showed poor understanding of treatment disclosures compared to the control group, and diminished new-learning and executive function correlated with poorer understanding. Nonetheless, with sufficient cueing, the MS patients with diminished neuropsychological function were able to display understanding that was equivalent to the control group. Implications of these results for clinical practice and medical research involving people with MS are discussed.
Basso, Michael R.; Candilis, Philip J.; Johnson, Jay; Ghormley, Courtney; Combs, Dennis R.; Ward, Taeh
Modern medicine is characterized by an "explosion" in clinical research information making practical application of Evidence-Based Medicine (EBM), problematic for many clinicians. We have developed a PICO-(evidence based search strategy focusing on Patient/Population, Intervention, Comparison and Outcome)-based framework for (indexing and retrieving medical evidence and we posit that the use of PICO allows for organizing evidence that is aligned with an MD's decision making model. We describe a study where medical students evaluated our PICO-based approach and results show that students are eager to apply EBM but are hindered by a lack of specialist skills. Students reported that the PICO-based framework for organizing evidence provided an intuitive way of accessing and evaluating evidence and would be useful for their clinical tasks. PMID:23920831
O'Sullivan, Dympna; Wilk, Szymon; Michalowski, Wojtek; Farion, Ken
This is the sixth edition of Global Import Regulations for Pre-Owned Medical Devices, which was first issued in May 1999. This report seeks to collect and compile information on the regulations relating to the importation of pre-owned (used and refurbishe...
Because environmental problems are growing and resources for dealing with them are shrinking, the environmental movement is witnessing an evolutionary shift toward greater emphasis on the use of risk assessment and management tools in setting environmental standards, determining levels of cleanup and deciding environmental program funding priorities. This change has important ramifications for the Department of Energy (DOE) and its national laboratories in terms of the costs of weapons facilities cleanup, the types of cleanup technology that will be emphasized and the way the DOE programs will be run. Other Federal agencies responsible for cleanup operations [e.g., the Environmental Protection Agency (EPA) and the Department of Defense (DOD)] will be similarly affected. This paper defines risk management and risk assessment and explains why these concepts will be of growing importance in the 1990s. It also defines other relevant terms. The paper develops a rationale for why risk assessment and management will be of increasing importance in environmental decision-making in the 1990s and beyond.
Ten medicallyimportant Saccharomyces strains, comprising six clinical isolates of Saccharomyces cerevisiae and four probiotic strains of Saccharomyces boulardii ,w ere characterized at the genetic and metabolic level and compared with non-medical, commercial yeast strains used in baking and wine-making. Strains were compared by genetic fingerprinting using amplified fragment length polymorphism (AFLP) analysis, by ribosomal DNA ITS1 sequencing and by
Donald A. MacKenzie; Marianne Defernez; Warwick B. Dunn; Marie Brown; Linda J. Fuller; Andreas Günther; Steve A. James; John Eagles; Mark Philo; Royston Goodacre; Ian N. Roberts
\\u000a In this paper, we provide an overview of the first workshop on Medical Content–Based Retrieval for Clinical Decision Support\\u000a (MCBR–CDS), which was held in conjunction with the Medical Image Computing and Computer Assisted Intervention (MICCAI) conference\\u000a in 2009 in London, UK. The goal of the workshop was to bring together researchers from diverse communities including medical\\u000a image analyses, text and
Henning Müller; Jayashree Kalpathy-Cramer; Barbara Caputo; Tanveer Fathima Syeda-Mahmood; Fei Wang
Biomass burning emissions from wildland and prescribed fires can have far reaching impacts in several of EPA’s regulatory programs under the Clean Air Act, ultimately affecting decisions on actions taken under State Implementation Plans (SIPs), and programs such as Visibility and Regional Haze, Interstate Transport and Conformity. In most instances the EPA’s National Emissions Inventory (NEI), which is developed in conjunction with other federal, state, local, and tribal agencies is a cornerstone used to support air quality decision making. Over the past several years estimated wildland and prescribed fire emissions in the NEI have evolved from a crude, state-based, climatology to fire-specific, daily-resolved estimates primarily through the use of satellite measurements. In addition to research within EPA, external research partners are providing improved knowledge in areas such as chemical composition of smoke, plume rise measurements via satellites, and the development of improved emission algorithms. Accurate inputs to characterize and model the daily and hourly biomass burning emissions across the US are necessary to reduce the uncertainty in characterizing the emissions, transport, and transformation of gases and particles from their source, with the end goal of categorizing biomass burning emissions within the EPA’s regulatory structure. Reducing the uncertainty will lead to improved decision making as this information is used to support the development and implementation of EPA’s air regulatory programs. This is especially true under the National Ambient Air Quality Standards (NAAQS) where averaging times for particulate matter (PM), ozone, and the new proposed NO2 standard are at 24 hours or less, where accurate resolution of fire emissions is critical in understanding receptor impacts. This talk will highlight the impacts of wildland and prescribed fires within EPA’s regulatory program and importance of continued research to reduce the uncertainly in the areas of chemical speciation, emission factors, plume rise, fuel loading, and fire behavior modeling. Disclaimer: Although this work was reviewed by the U.S. Environmental Protection Agency and approved for publication, it may not necessarily reflect official Agency policy.
Szykman, J. J.; Kordzi, J.; Pouliot, G.; Pierce, T. E.; Pace, T.; Rao, T.
Background Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission. Methods We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results. Results We identified 22 studies involving a total of 3755 patients (range 33–1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%– 61% had at least 1 omission error (deletion of a drug used before admission), and 13%– 22% had at least 1 commission error (addition of a drug not used before admission); 60%– 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%– 54% of patients had at least 1 medication history error and that 19%– 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%–59% of the medication history errors were clinically important. Interpretation Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.
Tam, Vincent C.; Knowles, Sandra R.; Cornish, Patricia L.; Fine, Nowell; Marchesano, Romina; Etchells, Edward E.
One of the most important problems on rule induction methods is that they cannot extract rules, which plausibly represent\\u000a experts’ decision processes. On one hand, rule induction methods induce probabilistic rules, the description length of which\\u000a is too short, compared with the experts’ rules. On the other hand, construction of Bayesian networks generates too lengthy\\u000a rules. In this paper, the
One of the most important problems on rule induction methods is that they cannot extract rules, which plausibly represent\\u000a experts’ decision processes. On one hand, rule induction methods induce probabilistic rules, the description length of which\\u000a is too short, compared with the experts’ rules. On the other hand, construction of Bayesian networks generates too lengthy\\u000a rules. In this paper, the
A neo-Darwinian heuristic for decisions involving altruism is hypothesized in this article. Following W. Hamilton's (1964) analysis of inclusive fitness, the assumption of this study is that tendencies to help another person are selected against, except when the donor and recipient are related and share genes underlying these tendencies. An important social psychological implication of Hamilton's formulation is that in
Eugene Burnstein; Christian Crandall; Shinobu Kitayama
This article examines the decision?making processes that Western Australian parents utilise when deciding whether to medicate or not to medicate their child diagnosed with Attention Deficit Hyperactivity Disorder. Thirty?three parents (five fathers and 28 mothers) from a wide range of socio?economic status suburbs in Perth, Western Australia were interviewed. A grounded theory of “doing right by my child” emerged from
In a study on penalty decisions in soccer, one hundred-fifteen participants who were either referees or players made decisions as referees for each of 20 videotaped scenes from an actual match. In three scenes, potential fouls were committed by defenders in their penalty areas. The first two scenes involved the same team and the third scene occurred in the penalty
|Three key political decisions made in Tennessee higher education that have brought about major changes in structure and have implications for the future are discussed. The decisions are: creation of the Tennessee Higher Education Commission (THEC) in 1967, the creation of the State Board of Regents (SBR) in 1972, and the establishment of the…
Limited information is available about the childbearing decision-making experience by the pregnant adolescent. The purpose of this case study was to explore this experience with three pregnant teenagers. The study is based on nine qualitative interviews. Within-case descriptions applying the theoretical model of decision-making regarding unwanted…
|Limited information is available about the childbearing decision-making experience by the pregnant adolescent. The purpose of this case study was to explore this experience with three pregnant teenagers. The study is based on nine qualitative interviews. Within-case descriptions applying the theoretical model of decision-making regarding unwanted…
|Background: While end-of-life decisions in the general population have received attention in several countries, not much is known about this in people with intellectual disabilities (IDs). Therefore, the prevalence and nature of end-of-life decisions were investigated in a Dutch centre providing residential care for 335 people with IDs. Method: A…
Wagemans, A.; van Schrojenstein Lantman-de-Valk, H.; Tuffrey-Wijne, I.; Widdershoven, G.; Curfs, L.
The current work sought to understand the ways in which family-level factors are related to youth's decisions regarding two hypothetical social dilemmas commonly faced by youth in high risk environments – deciding how to respond to persistent teasing and whether to intervene in a group fight. Specifically, the study focused on the relationship between African American youth's range of decisions
The application of PCR technology to molecular diagnostics holds great promise for the early identification of medicallyimportant pathogens. PCR has been shown to be useful for the detection of the presence of fungal DNA in both laboratory and clinical samples. Considerable interest has been focused on the utility of selecting universal primers, those that recognize constant regions among most,
THOMAS J. WALSH; ANDREA FRANCESCONI; MIKI KASAI; ANDSTEPHEN J. CHANOCK
A guide to stinging and biting invertebrates (prominently featuring insects and other arthropods) of the world. This guide is not meant for public dissemination nor sale, and was created primarily for military use. Types of interactions include envenomation, myiasis, urtication, allergic reactions as well as delusory parasitosis. The guide provides a good synopsis of most of the medicallyimportant insects and associated arthropods.
We characterized the antigenic cross-reactivity of two medicallyimportant North American Loxoxceles species: L. reclusa (native to southeastern US) and L. deserta (native to southwestern US). Dermonecrosis resulting from bites from these two North American spider species are indistinguishable clinically. Polyclonal IgG antivenins directed against L. reclusa and L. deserta were raised in rabbits and used to develop specific enzyme
H. F Gomez; M. J Miller; M. W Waggener; H. A Lankford; J. S Warren
Summary. A polymerase chain reaction (PCR) method was developed that was capable of detecting a wide range of medicallyimportant fungi from clinical specimens. The primer pair was designed in conserved sequences of 1 8s-ribosomal RNA genes shared by most fungi. The lower limit of detection of this PCR technique was 1 pg of Cundidu ulbicans genomic DNA by ethidium
In the context of a worldwide physician brain drain phenomenon, Lebanon has the highest emigration factor in the Middle East and North Africa. In this manuscript we aim to identify and develop a conceptual framework for the factors underlying the decisions of graduating Lebanese medical students to train abroad. We conducted two focus groups and seven semi-structured individual interviews with 23 students. In the deductive analysis (based on the push-pull theory), students reported push factors in Lebanon and pull factors abroad related to five dimensions. They focused predominantly on how training abroad provides them with a competitive advantage in an oversaturated Lebanese job market. An inductive analysis revealed the following emerging concepts: repel factors abroad and retain factors locally; societal expectations that students should train abroad; marketing of abroad training; and an established culture of migration. The marketing of abroad training and the culture of migration are prevalent in the academic institutions. PMID:17125896
In this study, a medical diagnosis decision support system based on hybrid genetic algorithm has been established to support the diagnosis of five common heart diseases (coronary heart disease, rheumatic valvular heart disease, hypertensive heart disease, chronic cor pulmonale and congenital heart disease). A heart disease database consisting of 352 samples was used for constructing and testing the performance of system. Cross-validation of the experimental results indicate that the system we established shows high capability of classifying these five kinds of heart diseases, the mean accuracy of classification is as high as 90.6%, and the user accuracy and procedure accuracy of each disease are both above 85.0%, showing great application prospect of supporting heart diseases diagnosis in clinics. PMID:15143564
Background: Ample evidence exists that clinical decision support (CDS) can improve clinician performance. Nevertheless, additional evidence demonstrates that clinicians still do not perform adequately in many instances. This suggests an ongoing need for implementation of CDS, in turn prompting development of a roadmap for national action regarding CDS. Objective: Develop practical advice to aid CDS implementation in order to improve clinician performance. Method: Structured group interview during a roundtable discussion by medical directors of information systems (N = 30), with subsequent review by participants and synthesis. Results: Participant consensus was that CDS should be comprehensive and should involve techniques such as order sets and facilitated documentation as well as alerts; should be subject to ongoing feedback; and should flow from and be governed by an organization’s clinical goals. Conclusion: A structured roundtable discussion of clinicians experienced in health information technology can yield practical, consensus advice for implementation of CDS.
Jenders, Robert A.; Osheroff, Jerome A.; Sittig, Dean F.; Pifer, Eric A.; Teich, Jonathan M
The use of over-the-counter (OTC) medication is an essential part of health care in the United States. The use of OTC medications for children is a particularly important topic as early research found that OTC medications may be used in lieu of obtaining ...
Accurate associative learning is often hindered by confirmation bias and success-chasing, which together can conspire to produce or solidify false beliefs in the decision-maker. We performed functional magnetic resonance imaging in 35 experienced physicians, while they learned to choose between two treatments in a series of virtual patient encounters. We estimated a learning model for each subject based on their observed behavior and this model divided clearly into high performers and low performers. The high performers showed small, but equal learning rates for both successes (positive outcomes) and failures (no response to the drug). In contrast, low performers showed very large and asymmetric learning rates, learning significantly more from successes than failures; a tendency that led to sub-optimal treatment choices. Consistently with these behavioral findings, high performers showed larger, more sustained BOLD responses to failed vs. successful outcomes in the dorsolateral prefrontal cortex and inferior parietal lobule while low performers displayed the opposite response profile. Furthermore, participants' learning asymmetry correlated with anticipatory activation in the nucleus accumbens at trial onset, well before outcome presentation. Subjects with anticipatory activation in the nucleus accumbens showed more success-chasing during learning. These results suggest that high performers' brains achieve better outcomes by attending to informative failures during training, rather than chasing the reward value of successes. The differential brain activations between high and low performers could potentially be developed into biomarkers to identify efficient learners on novel decision tasks, in medical or other contexts.
Objectives: It was investigated how students judge the teaching of medical ethics and the history of medicine at the start and during their studies, and the influence which subject-specific teaching of the history, theory and ethics of medicine (GTE) - or the lack thereof - has on the judgement of these subjects. Methods: From a total of 533 students who were in their first and 5th semester of the Bochum Model curriculum (GTE teaching from the first semester onwards) or followed the traditional curriculum (GTE teaching in the 5th/6th semester), questionnaires were requested in the winter semester 2005/06 and in the summer semester 2006. They were asked both before and after the 1st and 5th (model curriculum) or 6th semester (traditional curriculum). We asked students to judge the importance of teaching medical ethics and the history of medicine, the significance of these subjects for physicians and about teachability and testability (Likert scale from -2 (do not agree at all) to +2 (agree completely)). Results: 331 questionnaire pairs were included in the study. There were no significant differences between the students of the two curricula at the start of the 1st semester. The views on medical ethics and the history of medicine, in contrast, were significantly different at the start of undergraduate studies: The importance of medical ethics for the individual and the physician was considered very high but their teachability and testability were rated considerably worse. For the history of medicine, the results were exactly opposite. GTE teaching led to a more positive assessment of items previously ranked less favourably in both curricula. A lack of teaching led to a drop in the assessment of both subjects which had previously been rated well. Conclusion: Consistent with the literature, our results support the hypothesis that the teaching of GTE has a positive impact on the views towards the history and ethics of medicine, with a lack of teaching having a negative impact. Therefore the teaching of GTE should already begin in the 1st semester. The teaching of GTE must take into account that even right at the start of their studies, students judge medical ethics and the history of medicine differently.
Previous tests of the influence of race on decision making within juvenile justice proceedings have traditionally focused\\u000a on case-level variables and\\/or macrolevel factors that characterize the jurisdictions under study. Often excluded are measures\\u000a of the attitudinal context within which decision making occurs. Using a revised conflict perspective that incorporates the\\u000a role of racial stereotyping, hypotheses are developed centering on racial
OBJECTIVE: To study nonmedical influences on the doctor-patient interaction. A technique using simulated patients and "real" doctors is described. DATA SOURCES: A random sample of physicians, stratified on such characteristics as demographics, specialty, or experience, and selected from commercial and professional listings. STUDY DESIGN: A medical appointment is depicted on videotape by professional actors. The patient's presenting complaint (e.g., chest pain) allows a range of valid interpretation. Several alternative versions are taped, featuring the same script with patient-actors of different age, sex, race, or other characteristics. Fractional factorial design is used to select a balanced subset of patient characteristics, reducing costs without biasing the outcome. DATA COLLECTION: Each physician is shown one version of the videotape appointment and is asked to describe how he or she would diagnose or treat such a patient. PRINCIPAL FINDINGS: Two studies using this technique have been completed to date, one involving chest pain and dyspnea and the other involving breast cancer. The factorial design provided sufficient power, despite limited sample size, to demonstrate with statistical significance various influences of the experimental and stratification variables, including the patient's gender and age and the physician's experience. Persistent recruitment produced a high response rate, minimizing selection bias and enhancing validity. CONCLUSION: These techniques permit us to determine, with a degree of control unattainable in observational studies, whether medicaldecisions as described by actual physicians and drawn from a demographic or professional group of interest, are influenced by a prescribed set of nonmedical factors.
Feldman, H A; McKinlay, J B; Potter, D A; Freund, K M; Burns, R B; Moskowitz, M A; Kasten, L E
Standard models of adolescent risk-taking posit that the cognitive abilities of adolescents and adults are equivalent, and that increases in risk-taking that occur during adolescence are the result of socioemotional differences in impulsivity, sensation seeking, and lack of self-control. Fuzzy-trace theory incorporates these socioemotional differences. However, it predicts that there are also cognitive differences between adolescents and adults, specifically that there are developmental increases in gist-based intuition that reflects understanding. Gist understanding, as opposed to verbatim-based analysis, generally has been hypothesized to have a protective effect on risk-taking in adolescence. Gist understanding is also an essential element of informed consent regarding risks in medicaldecision-making. Evidence thus supports the argument that adolescents’ status as mature minors should be treated as an exception rather than a presumption, as accuracy in verbatim analysis is not mature gist understanding. Use of the exception should be accompanied by medical experts’ input on the bottom-line gist of risks involved in treatment.
Background: Physical activity (PA) is powerful for preventing and treating many chronic diseases. Physicians' own PA behaviors are correlated with their likelihood to counsel patients regarding PA. Medical students' PA-related attitudes and behaviors reflect what can be expected from our future physicians. Methods: A 27-item online survey was used to determine the percentage of Canadian medical students meeting the Canadian physical activity recommendations, and their self-reported perception of relevance and frequency of exercise counseling during patient encounters. We generated cross-tabulations with the independent covariates and our statistical comparison was based on the generalized estimating equation (GEE) algorithm to adjust for schools (clusters). Results: While 64% (969/1510) of medical students met the MVPA recommendation, only 25% discussed PA counseling with patients. Most (80% and 90%, respectfully) believed physicians should adhere to a healthy lifestyle to effectively encourage their patients to do so, and that their credibility increased if they stayed fit themselves. Conclusions: Medical students are interested in and receptive to the importance of PA. However, not only is there improvement needed for the more than one-third of medical students who are insufficiently active themselves, but substantial change is needed regarding the vast majority of students' current counseling behaviors. PMID:23072743
Background: Physical activity (PA) is powerful for preventing and treating many chronic diseases. Physicians' own PA behaviors are correlated with their likelihood to counsel patients regarding PA. Medical students' PA-related attitudes and behaviors reflect what can be expected from our future physicians. Methods: A 27-item online survey was used to determine the percentage of Canadian medical students meeting the Canadian physical activity recommendations, and their self-reported perception of relevance and frequency of exercise counseling during patient encounters. We generated cross-tabulations with the independent covariates and our statistical comparison was based on the generalized estimating equation (GEE) algorithm to adjust for schools (clusters). Results: While 64% (969/1510) of medical students met the MVPA recommendation, only 25% discussed PA counseling with patients. Most (80% and 90%, respectfully) believed physicians should adhere to a healthy lifestyle to effectively encourage their patients to do so, and that their credibility increased if they stayed fit themselves. Conclusions: Medical students are interested in and receptive to the importance of PA. However, not only is there improvement needed for the more than one-third of medical students who are insufficiently active themselves, but substantial change is needed regarding the vast majority of students' current counseling behaviors. PMID:23978834
Healthcare decision-making can be complex, often requiring decision makers to weigh serious trade-offs, consider patients’ values, and incorporate evidence in the face of uncertainty. Medicaldecisions are made implicitly by clinicians and other decision-makers on a daily basis. Decisions based largely on personal experience are subject to many biases. Decision analysis and cost-effectiveness analysis are systematic approaches used to support decision-making under conditions of uncertainty that involve important trade-offs. These mathematical tools can provide patients, physicians and policy makers with a useful approach to complex medicaldecision making.
Ryder, Hilary F.; McDonough, Christine; Tosteson, Anna N. A.; Lurie, Jon D.
The Drug Enforcement Administration (DEA) is amending its regulations to expressly incorporate the restrictions on personal use importation imposed by Congress in 1998 and to expand upon those restrictions to curtail the diversion that has continued even after the 1998 congressional amendment. Specifically, DEA is limiting to 50 dosage units the total amount of controlled substances that a United States resident may bring into the United States for legitimate personal medical use when returning from travel abroad at any location and by any means. This regulation will help prevent importation of controlled substances for unlawful use while still accommodating travelers who have a legitimate medical need for controlled substances during their journey. PMID:15366181
Background Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. Methods We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers’ assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP ?140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG ?20% is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. Results 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3%. Adherence assessments by providers correlated poorly with refill history. 211 (20%) patients did not have BP medication available for???20% of days; providers characterized 79 (37%) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46%). Providers intensified BP medications for 451 (42%) patients, similarly whether assessed by provider as having significant non-adherence (44%) or not (43%). Conclusions Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.
Translational medicine entails not only “from-bench-to-bedside” but also preventive medicine. The present article proposes a conceptual framework of translational research from scientific research to health care policy and public health policy. We highlight the importance of translational medicine to bridge between research and policy and share our experience of translating medical research to public health policy in China as well as obstacles and challenges we are facing in the translation process.
Nucleic Acid Sequence Based Amplification (NASBA), an isothermal amplification technique for nucleic acids, was evaluated for the identification of medicallyimportant Candida species using primers selected from 18S rRNA sequences conserved in fungi. An RNA fragment of 257 nucleotides was amplified for Candida albicans. Nineteen different fungi were tested for rRNA amplification with the NASBA. All were positive when analyzed
Myra N. Widjojoatmodjo; Annemarie Borst; Rianne A. F. Schukkink; Adrienne T. A. Box; Nicole M. M. Tacken; Bob Van Gemen; Jan Verhoef; Bert Top; Ad. C. Fluit
Recent experimental values of X-ray mass attenuation coefficients for the elements zota = 6 to zota = 18 in the energy range from 4 to 25 keV suggest improvements to the data set presented in the ICRU Report 17. The results are, however, in excellent agreement with the theoretical data of Storm and Israel (1970). Values of mass attenuation coefficient for these elements and for a selection of materials of medical and biological importance are presented. PMID:1202514
The fine structure of Chrysomya nigripes Aubertin, a blow fly species of medicalimportance, is presented using scanning electron microscopy (SEM) to contribute information\\u000a on the morphology of the adult of this fly species. The surface of the dome-shaped ommatidia exhibits a microscopic granulose\\u000a appearance. The palpus is equipped with small sensilla basiconica and sensilla chaetica, which provide sensory reception
Radchadawan Ngern-klun; Kom Sukontason; Rungkanta Methanitikorn; Roy C. Vogtsberger; Kabkaew L. Sukontason
In a survey carried out during Summer and Autumn of 2004, for snails of medicalimportance, nine species were recovered. These were Biomphalaria alexandrina, B. glabrata, B. pfeifferi, Bulinus truncatus, B. forskalii, Lymnaea natalensis, Bellamya (=Vivipara) unicolor, Physa acuta and Hydrobia musaensis. Parasitological examination revealed that B. alexandrina, B. glabrata and L. natalensis harboured immature stages of their concerned trematode parasites. Moreover, P. acuta harboured the immature stage of the nematode parasite Parastrongylus cantonensis. PMID:15880994
Abo-Madyan, Ahmed A; Morsy, Tosson A; Motawea, Saad M; El Garhy, Manal F; Massoud, Ahmed M A
...APHIS-2011-0039] Notice of Decision To Authorize the Importation of Fresh Apricot, Sweet Cherry, and Plumcot Fruit From South Africa Into the Continental United States Correction In notice document 2011-25490 appearing on pages 61340-61341 in...
|Based on three independent samples from Germany and the United States, this exploratory, cross-cultural study examines empirically the importance of ethical training for the improvement of ethical decision-making. The results of the study reveal a significant difference in the use of corporate codes of conduct and ethical training, as well as…
Objectives To determine whether free access to research articles on bmj.com is an important factor in authors' decisions on whether to submit to the BMJ, whether the introduction of access controls to part of the BMJ's content has influenced authors' perceptions of the journal, and whether the introduction of further access controls would influence authors' perceptions. Design Cross sectional electronic
Systematic biases in decision-making have been well characterized in medical and nonmedical fields but mostly ignored in clinical psychopharmacology. The purpose of this paper is to sensitize clinicians who prescribe psychiatric drugs to the issues of the psychology of risk, especially as they pertain to the risk of side effects. Specifically, the present analysis focuses on heuristic organization and framing
Andrew A. Nierenberg; Jordan W. Smoller; Polina Eidelman; Yelena P. Wu; Claire A. Tilley
Medical problems involve different types of variables and data, which have to be processed, analyzed and synthesized in order to reach a decision and\\/or conclude to a diagnosis. Usually, information and data set are both symbolic and numeric but most of the well-known data analysis methods deal with only one kind of data. Even when fuzzy approaches are considered, which
Elpiniki Papageorgiou; Chrysostomos Stylios; Peter Groumpos
In this research work, a novel framework for the construction of augmented Fuzzy Cognitive Maps based on Fuzzy Rule-Extraction methods for decisions in medical informatics is investigated. Specifically, the issue of designing augmented Fuzzy Cognitive Maps combining knowledge from experts and knowledge from data in the form of fuzzy rules generated from rule-based knowledge discovery methods is explored. Fuzzy cognitive
Biomass burning emissions from wildland and prescribed fires can have far reaching impacts in several of EPA?s regulatory programs under the Clean Air Act, ultimately affecting decisions on actions taken under State Implementation Plans (SIPs), and programs such as Visibility and...
|This study examines some of the characteristics of decision-making on school boards, focusing on the behavior of southern school board members in comparison with their counterparts in other regions of the country. Data were collected in 1975 at the convention of the National School Boards Association (NSBA). Self-administered questionnaires were…
Previously the authors analyzed sets of words used in emotion Stroop experiments and found little evidence of automatic vigilance, for example, slower lexical decision time (LDT) or naming speed for negative words after controlling for lexical features. If there is a slowdown evoked by word negativity, most studies to date overestimate the effect because word negativity is often confounded with
Randy J. Larsen; Kimberly A. Mercer; David A. Balota; Michael J. Strube
Most of the theoretical and empirical literature on violence risk to date has focused on the task of predicting who will behave violently. In the present article, it is argued that at least two models of risk assessment may be applied to the varying legal decisions in which violence risk is a consideration: prediction (with an emphasis on overall accuracy)
We use a laboratory experiment to compare the way groups and individuals behave in an inter-temporal common pool dilemma. The experimental design distinguishes between a non-strategic problem where players (individuals or groups of three) make decisions without interaction and a strategic part where players harvest from a common pool. This allows us to correct for differences between individuals and groups
Ten medicallyimportant Saccharomyces strains, comprising six clinical isolates of Saccharomyces cerevisiae and four probiotic strains of Saccharomyces boulardii, were characterized at the genetic and metabolic level and compared with non-medical, commercial yeast strains used in baking and wine-making. Strains were compared by genetic fingerprinting using amplified fragment length polymorphism (AFLP) analysis, by ribosomal DNA ITS1 sequencing and by metabolic footprinting using both direct injection mass spectrometry (DIMS) and gas chromatography-time of flight-mass spectrometry (GC-ToF-MS). Overall, the clinical isolates fell into different groupings when compared with the non-medical strains, with good but not perfect correlation amongst strains at both the genetic and metabolic levels. Probiotic strains of S. boulardii that are used therapeutically to treat human gastro-intestinal tract disorders showed tight clustering both genetically and metabolically. Metabolomics was found to be of value both as a taxonomic tool and as a means to investigate anomalous links between genotype and phenotype. Key discriminatory metabolites were identified when comparing the three main groups of clinical, probiotic and non-medical strains and included molecules such as trehalose, myo-inositol, lactic acid, fumaric acid and glycerol 3-phosphate. This study confirmed the link between a subset of clinical isolates and baking or probiotic strains but also highlighted that in general the clinical strains were more diverse at both the genomic and metabolic levels. PMID:18615862
MacKenzie, Donald A; Defernez, Marianne; Dunn, Warwick B; Brown, Marie; Fuller, Linda J; de Herrera, Santiago R M Seco; Günther, Andreas; James, Steve A; Eagles, John; Philo, Mark; Goodacre, Royston; Roberts, Ian N
Objective: We sought to quantify clinical decision points for identifying depression treatment nonremitters prior to end-of-treatment. Method: Data came from the psychotherapy arms of a randomized clinical trial for chronic depression. Participants (n = 352; 65.6% female; 92.3% White; mean age = 44.3 years) received 12 weeks of cognitive behavioral analysis system of psychotherapy (CBASP) or CBASP plus an antidepressant medication. In half of the sample, receiver operating curve analyses were used to identify efficient percentage of symptom reduction cut points on the Inventory of Depressive Symptoms-Self-Report (IDS-SR) for predicting end-of-treatment nonremission based on the Hamilton Rating Scale for Depression (HRSD). Sensitivity, specificity, predictive values, and Cohen's kappa for identified cut points were calculated using the remaining half of the sample. Results: Percentage of IDS-SR symptom reduction at Weeks 6 and 8 predicted end-of-treatment HRSD remission status in both the combined treatment (Week 6 cut point = 50.0%, Cohen's ? = .42; Week 8 cut point = 54.3%, Cohen's ? = .45) and psychotherapy only (Week 6 cut point = 60.7%, Cohen's ? = .41; Week 8 cut point = 48.7%, Cohen's ? = .49). Status at Week 8 was more reliable for identifying nonremitters in psychotherapy-only treatment. Conclusions: Those with chronic depression who will not remit in structured, time-limited psychotherapy for depression, either with therapy alone or in combination with antidepressant medication, are identifiable prior to end of treatment. Findings provide an operationalized strategy for designing adaptive psychotherapy interventions. (PsycINFO Database Record (c) 2013 APA, all rights reserved). PMID:23750462
Steidtmann, Dana; Manber, Rachel; Blasey, Christine; Markowitz, John C; Klein, Daniel N; Rothbaum, Barbara O; Thase, Michael E; Kocsis, James H; Arnow, Bruce A
Abstract Background: We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior. Methods: Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse. Results: Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling. Conclusions: Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception. PMID:23930947
Schwarz, Eleanor Bimla; Parisi, Sara M; Handler, Steven M; Koren, Gideon; Shevchik, Grant; Fischer, Gary S
In Norway, a National Insurance Board decides whether patients treated abroad should have their expenses reimbursed. Its decisions may be appealed to an independent governmental board of appeals. This article presents the appeals procedure and discusses the experience gained over its first three years. The most important criterion for reimbursement is whether there is a lack of expertise in Norway on the relevant condition, which must be severe. A statement must be sought from a tertiary-level hospital about the proposed intervention. A referral or recommendation is not required. Reimbursement will not be considered for interventions defined as experimental, except in conditions that are so rare that the number of patients in Norway will be so small that one cannot expect large-scale randomised trials organised in this country. During its first three years, the board of appeals considered 184 cases; decisions were revered in 21 cases (11%). The appeals procedure remains well known among the public. Doctors should make themselves familiar with the criteria and the appeals procedure. PMID:12119782
Norheim, Ole Frithjof; Fougner, Jan; Søreide, Odd; Storm-Mathisen, Ingebjørg; Strengehagen, Ellen
There are a number of different quantitative models that can be used in a medical diagnostic decision support system (MDSS) including parametric methods (linear discriminant analysis or logistic regression), non-parametric models (K nearest neighbor, or kernel density) and several neural network models. The complexity of the diagnostic task is thought to be one of the prime determinants of model selection. Unfortunately, there is no theory available to guide model selection. Practitioners are left to either choose a favorite model or to test a small subset using cross validation methods. This paper illustrates the use of a self-organizing map (SOM) to guide model selection for a breast cancer MDSS. The topological ordering properties of the SOM are used to define targets for an ideal accuracy level similar to a Bayes optimal level. These targets can then be used in model selection, variable reduction, parameter determination, and to assess the adequacy of the clinical measurement system. These ideas are applied to a successful model selection for a real-world breast cancer database. Diagnostic accuracy results are reported for individual models, for ensembles of neural networks, and for stacked predictors. PMID:10998586
The present study examined the sociometer’s role in guiding social behavior. The authors hypothesized that low self-esteem people (LSEs), but not high self-esteem people (HSEs), base their social decision-making on acceptance. Undergraduate participants were invited to join a social group and were led to believe that acceptance either was guaranteed, or was likely but not guaranteed. HSEs always were eager
Previous research showed that object decision priming was found for possible, but not impossible, three-dimensional objects\\u000a (e.g., Schacter, Cooper, & Delaney, 1990; Schacter, Cooper, Delaney, Peterson, & Tharan, 1991). We tested those objects and\\u000a found that the impossible objects were subjectively more complex than the possible objects. We then constructed two sets of\\u000a possible and impossible objects—one set that was
Medical problems involve different types of variables and data, which have to be processed, analyzed and synthesized in order to reach a decision and/or conclude to a diagnosis. Usually, information and data set are both symbolic and numeric but most of the well-known data analysis methods deal with only one kind of data. Even when fuzzy approaches are considered, which are not depended on the scales of variables, usually only numeric data is considered. The medicaldecision support methods usually are accessed in only one type of available data. Thus, sophisticated methods have been proposed such as integrated hybrid learning approaches to process symbolic and numeric data for the decision support tasks. Fuzzy Cognitive Maps (FCM) is an efficient modelling method, which is based on human knowledge and experience and it can handle with uncertainty and it is constructed by extracted knowledge in the form of fuzzy rules. The FCM model can be enhanced if a fuzzy rule base (IF-THEN rules) is available. This rule base could be derived by a number of machine learning and knowledge extraction methods. Here it is introduced a hybrid attempt to handle situations with different types of available medical and/or clinical data and with difficulty to handle them for decision support tasks using soft computing techniques. PMID:18002176
Papageorgiou, Elpiniki; Stylios, Chrysostomos; Groumpos, Peter
The Connecticut State Medical Society (CSMS) reviews and accredits the continuing medical education (CME) programs offered by Connecticut's hospitals. As part of the survey process, the CSMS assesses the quality of the hospitals' libraries. In 1987, the CSMS adopted the Medical Library Association's (MLA's) “Minimum Standards for Health Sciences Libraries in Hospitals.” In 1990, professional librarians were added to the survey team and, later, to the CSMS CME Committee. Librarians participating in this effort are recruited from the membership of the Connecticut Association of Health Sciences Librarians (CAHSL). The positive results of having a qualified librarian on the survey team and the invaluable impact of adherence to the MLA standards are outlined. As a direct result of this process, hospitals throughout the state have added staffing, increased space, and added funding for resources during an era of cutbacks. Some hospital libraries have been able to maintain a healthy status quo, while others have had proposed cuts reconsidered by administrators for fear of losing valuable CME accreditation status. Creating a relationship with an accrediting agency is one method by which hospital librarians elsewhere may strengthen their efforts to ensure adequate library resources in an era of downsizing. In addition, this collaboration has provided a new and important role for librarians to play on an accreditation team.
Most of the theoretical and empirical literature on violence risk to date has focused on the task of predicting who will behave violently. In the present article, it is argued that at least two models of risk assessment may be applied to the varying legal decisions in which violence risk is a consideration: prediction (with an emphasis on overall accuracy) and management (with an emphasis on risk reduction). These two models are described, and discussed in the contexts of the literatures on forensic assessment and therapeutic jurisprudence. The implications for research, policy, and practice are considered. PMID:9335193
Animal scientists have recently found a way to produce extremely pale grain-fed veal, thus achieving high quality grade, while averting concerns over unethical treatment and medication residues in milk-fed veal production. Consumers, however, may reject pale cuts of veal labeled as “grain-fed.” This article uses questionnaire data from six groceries in the province of Quebec, Canada, to investigate frequency of
Gale E. West; Bruno Larue; Chedlia Touil; Shannon L. Scott
We are advising the public of our decision to authorize the importation into the continental United States of fresh persimmon fruit from the Republic of South Africa. Based on the findings of a pest risk analysis, which we made available to the public for review and comment through a previous notice, we believe that the application of one or more designated phytosanitary measures will be......
We are advising the public of our decision to authorize the importation of fresh litchi from the Republic of South Africa into the continental United States. Based on the findings in a pest risk analysis, which we made available to the public for review and comment through a previous notice, we believe that the application of one or more designated phytosanitary measures will be sufficient to......
We are advising the public of our decision to authorize the importation into the continental United States of fresh apricot, sweet cherry, and plumcot fruit from South Africa. Based on the findings of a pest risk analysis, which we made available to the public for review and comment through a previous notice, we believe that the application of one or more designated phytosanitary measures will be......
Objective To identify cognitive predictors of medicaldecision-making capacity (MDC) in participants with traumatic brain injury (TBI) at time of acute injury (baseline) and at six-month follow-up. Participants At baseline, participants were 34 adults with moderate to severe TBI and 20 healthy adults. At six-month follow-up, participants were 24 adults with moderate to severe TBI and 20 normal adults. Main Outcome Measures Participants were administered a consent capacity instrument (Capacity to Consent to Treatment Instrument: CCTI) and neuropsychological test measures. In the TBI group, univariate and multivariate cognitive predictor models were developed at baseline and six-month follow-up for clinically relevant CCTI consent abilities/standards (S) of understanding (S5); reasoning (S4); and appreciation (S3). Results At baseline, measures of short-term verbal memory and semantic fluency predicted TBI group performance on understanding (S5); short-term verbal memory and attention predicted performance on reasoning (S4); and working memory predicted performance on appreciation (S3). Regarding six-month follow-up models, measures of basic executive function, verbal processing speed, and working memory predicted TBI performance on understanding (S5); working memory and short-term memory predicted reasoning (S4); and basic executive functioning predicted appreciation (S3). Conclusions Multiple cognitive functions are associated with acute impairment and partial recovery of MDC in patients with moderate to severe TBI. Short-term verbal memory was strongly associated with impairments in consent capacity in TBI participants at the time of acute inpatient hospitalization. As patients experience cognitive and functional recovery post-hospitalization, executive functioning and working memory abilities were associated with improved capacity at six-month follow-up. The results offer insight into the relationship between different standards of competency and cognitive changes and recovery following acute TBI.
Dreer, Laura E.; DeVivo, Michael J.; Novack, Thomas A.; Krzywanski, Sara; Marson, Daniel C.
Background The decision to issue sickness certification in Sweden for a patient should be based on the physician's assessment of the reduction of the patient's work capacity due to a disease or injury, not on psychosocial factors, in spite of the fact that they are known as risk factors for sickness absence. The aim of this study was to investigate the influence of medical factors and functioning on sick listing probability. Methods Four hundred and seventy-four patient-physician consultations, where sick listing could be an option, in general practice in Örebro county, central Sweden, were documented using physician and patient questionnaires. Information sought was the physicians' assessments of causes and consequences of the patients' complaints, potential to recover, diagnoses and prescriptions on sick leave, and the patients' view of their family and work situation and functioning as well as data on the patients' former and present health situation. The outcome measure was whether or not a sickness certificate was issued. Multivariate analyses were performed. Results Complaints entirely or mainly somatic as assessed by the physician decreased the risk of sick listing, and complaints resulting in severe limitation of occupational work capacity, as assessed by the patient as well as the physician, increased the risk of sick listing, as did appointments for locomotor complaints. The results for patients with infectious diseases or musculoskeletal diseases were partly similar to those for all diseases. Conclusion The strongest predictors for sickness certification were patient's and GP's assessment of reduced work capacity, with a striking concordance between physician and patient on this assessment. When patient's complaints were judged to be non-somatic the risk of sickness certification was enhanced.
Norrmen, Gunilla; Svardsudd, Kurt; Andersson, Dan KG
Background Many drugs are available for control of hypertension and its sequels in Nigeria but some are not affordable for majority of the populace. This serious pharmacoeconomic question has to be answered by the nation’s health economists. The objective of this study was to evaluate the cost-effectiveness of drugs from 4 classes of antihypertensive medications commonly used in Nigeria in management of hypertension without compelling indication to use a particular antihypertensive drug. Methods The study employed decision analytic modeling. Interventions were obtained from a meta-analysis. The Markov process model calculated clinical outcomes and costs during a life cycle of 30 years of 1000 hypertensive patients stratified by 3 cardiovascular risk groups, under the alternative intervention scenarios. Quality adjusted life year (QALY) was used to quantify clinical outcome. The average cost of treatment for the 1000 patient was tracked over the Markov cycle model of the alternative interventions and results were presented in 2010 US Dollars. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability frontiers. Expected value of perfect information (EVPI) and expected value of parameter perfect information (EVPPI) analyses were also conducted for the hypothetical population. Results Thiazide diuretic was the most cost-effective option across the 3 cardiovascular risk groups. Calcium channel blocker was the second best for Moderate risk and high risk with a willingness to pay of at least 2000$/QALY. The result was robust since it was insensitive to the parameters alteration. Conclusions The result of this study showed that thiazide diuretic followed by calcium channel blocker could be a feasible strategy in order to ensure that patients in Nigeria with hypertension are better controlled.
ObjectiveTo assess the performance of the pandemic medical early warning score (PMEWS) in a cohort of adult patients seen in the community by emergency care practitioners (ECP) and its correlation with ECP decision-making to either ‘treat and leave’ or transfer for hospital assessment.MethodsCases attended by ECP in South Yorkshire in 2007 in which the final ECP working diagnosis was a
PurposeClinical guidelines for cardiometabolic risk management indicate a simple threshold-based strategy for treatment, but physicians and their patients may be reluctant to modify drug treatment after a single elevated measurement. We determined how repeated measurements of blood pressure, cholesterol and haemoglobin A1c affect general practitioners' decisions to start or intensify medication in patients with type 2 diabetes. We also evaluated
J. Voorham; F. M. Haaijer-Ruskamp; B. H. R. Wolffenbuttel; R. P. Stolk; P. Denig
While the use of p-values in evidence-based medicine (EBM) is consistent and well-defined, the application of statistical information in health law varies greatly. A comparative literature review of clinical and legal medicaldecision making using Medline (PubMed) and LexisNexis reveals large disparities in the mode and frequency with which statistical evidence is used in EBM when compared with health law.
Kelly H. Zou; L. M. DeTora; S. J. Haker; R. V. Mulkern
An important barrier to the widespread dissemination of clinical decision support (CDS) is the heterogeneity of information models and terminologies used across healthcare institutions, health information systems, and CDS resources such as knowledge bases. To address this problem, the Health Level 7 (HL7) Virtual Medical Record project (an open, international standards development effort) is developing community consensus on the clinical information exchanged between CDS engines and clinical information systems. As a part of this effort, the HL7 CDS Work Group embarked on a multinational, collaborative effort to identify a representative set of clinical data elements required for CDS. Based on an analysis of CDS systems from 20 institutions representing 4 nations, 131 data elements were identified as being currently utilized for CDS. These findings will inform the development of the emerging HL7 Virtual Medical Record standard and will facilitate the achievement of scalable, standards-based CDS.
Kawamoto, Kensaku; Del Fiol, Guilherme; Strasberg, Howard R.; Hulse, Nathan; Curtis, Clayton; Cimino, James J.; Rocha, Beatriz H.; Maviglia, Saverio; Fry, Emory; Scherpbier, Harm J.; Huser, Vojtech; Redington, Patrick K.; Vawdrey, David K.; Dufour, Jean-Charles; Price, Morgan; Weber, Jens H.; White, Thomas; Hughes, Kevin S.; McClay, James C.; Wood, Carla; Eckert, Karen; Bolte, Scott; Shields, David; Tattam, Peter R.; Scott, Peter; Liu, Zhijing; McIntyre, Andrew K.
During these last years, Algeria, like some other developing countries is undergoing important institutional changes. The structural adjustment plan (1990s), and the association agreement signed with the European Union (2005) are some of political tools that guide these profound changes that have considerable impacts on the strategic behavior of local enterprises. Beyond these mutations at national level, important policy changes
This article compares two practices for initiating treatment decision-making, evident in audio-recorded consultations between a neurologist and 13 patients in two hospital clinics in the UK. We call these 'recommending' and 'option-listing'. The former entails making a proposal to do something; the latter entails the construction of a list of options. Using conversation analysis (CA), we illustrate each, showing that the distinction between these two practices matters to participants. Our analysis centres on two distinctions between the practices: epistemic differences and differences in the slots each creates for the patient's response. Considering the implications of our findings for understanding medical authority, we argue that option-listing - relative to recommending - is a practice whereby clinicians work to relinquish a little of their authority. This article contributes, then, to a growing body of CA work that offers a more nuanced, tempered account of medical authority than is typically portrayed in the sociological literature. We argue that future CA studies should map out the range of ways - in addition to recommending - in which treatment decision-making is initiated by clinicians. This will allow for further evidence-based contributions to debates on the related concepts of patient participation, choice, shared decision-making and medical authority. PMID:23550963
This study aimed to determine nurses' tendency toward medical errors and identify the types of medical errors made. This article examined medical error trends of nurses with a survey. It is recommended that medical errors be recorded, various training activities be offered, and standards regarding nursing care and patient safety be determined. PMID:23774722
Waiting for medical test results that signal physical harm can be a stressful and potentially psychologically harmful experience. Despite this, interventionists and physicians often use this wait time to deliver behavior change messages and other important information about the test, possible results and its implications. This study examined how "bracing" for a medical test result impacts cognitive processing, as well as recall of information delivered during this period. Healthy U.S. university students (N = 150) were tested for a deficiency of a fictitious saliva biomarker that was said to be predictive of long-term health problems using a 2 (Test Result) x 2 (Expected immediacy of result: 10 min, 1 month) factorial design. Participants expecting to get the test result shortly should have been bracing for the result. While waiting for the test results participants completed measures of cognitive processing. After participants received the test result, recall of information about the biomarker was tested in addition to cognitive measures. One week later, participants who were originally told they did not have the deficiency had their recall assessed again. Results showed that anticipating an imminent test result increased cognitive distraction in the processing of information and lowered recall of information about the test and the biomarker. These results suggest that delivering critical information to patients after administering a test and immediately before giving the results may not be optimal. PMID:20570029
Waiting for medical test results that signal physical harm can be a stressful and potentially psychologically harmful experience. Despite this, interventionists and physicians often use this wait time to deliver behavior change messages and other important information about the test, possible results and its implications. This study examined how "bracing" for a medical test result impacts cognitive processing, as well as recall of information delivered during this period. Healthy U.S. university students (N = 150) were tested for a deficiency of a fictitious saliva biomarker that was said to be predictive of long-term health problems using a 2 (Test Result) x 2 (Expected immediacy of result: 10 min, 1 month) factorial design. Participants expecting to get the test result shortly should have been bracing for the result. While waiting for the test results participants completed measures of cognitive processing. After participants received the test result, recall of information about the biomarker was tested in addition to cognitive measures. One week later, participants who were originally told they did not have the deficiency had their recall assessed again. Results showed that anticipating an imminent test result increased cognitive distraction in the processing of information and lowered recall of information about the test and the biomarker. These results suggest that delivering critical information to patients after administering a test and immediately before giving the results may not be optimal. PMID:20556876
|The introduction of written informed consent in the 1970s created expectations of shared decision making between doctors and patients that has led to decisional conflict for some patients. This study utilized a collaborative, intrinsic case study approach to the decision-making process of oncology patients who participated in an open art therapy…
Given evidence of differences between UK medical schools' curricula and assessments, and their graduates' performance in Royal college examinations, this retrospective cohort study analyses the effect of medical school on the incidence of General Medical Council fitness to practise sanctions. PMID:24105312
Accidents involving venomous animals have always caught the attention of mankind due to their lethality and other clinical implications. However, since the molecules obtained from animal venoms have been the product of millions of years of evolutionary process, toxins could be used to probe physiological mechanisms and could serve as leads for drug development. The present work reviews the state of the art pertaining to venom molecules from Brazilian medicallyimportant arachnid species bearing potential biotechnological applications. Special focus is given to toxins isolated from the scorpion Tityus serrulatus and the spiders Phoneutria nigriventer and Lycosa erythrognatha, whose venoms possess molecules acting as erectile function modulators and as antihypertensive, analgesic, neuroprotective and antimicrobial agents. PMID:21824079
Rates, Breno; Verano-Braga, Thiago; Santos, Daniel Moreira; Nunes, Kênia Pedrosa; Pimenta, Adriano M C; De Lima, Maria Elena
This identification key has been prepared to enable field workers in eastern and centra Africa to identify the species and subspecies of snails acting as intermediate hosts of various flukes causing bilharziasis and related diseases in man and his domestic stock. The area covered by the key is eastern Africa from the Sudan and Somalia in the north to Southern Rhodesia in the south. The key includes all species and subspecies of the three medically and veterinarily important genera, Lymnaea, Bulinus and Biomphalaria. All other freshwater pulmonates of the area can be identified as to genus only. Those features of the shells and soft parts of snails which are used in identification are discussed in some detail, and indications are given as to methods of collection, preservation and dissection of snails.
Despite the clinical importance of bacterial-fungal interactions, their molecular details are poorly understood. A hallmark of such medicallyimportant interspecies associations is the interaction between the two nosocomial pathogens Staphylococcus aureus and Candida albicans, which can lead to mixed biofilm-associated infections with enhanced antibiotic resistance. Here, we use single-cell force spectroscopy (SCFS) to quantify the forces engaged in bacterial-fungal co-adhesion, focusing on the poorly investigated S. epidermidis-C. albicans interaction. Force curves recorded between single bacterial and fungal germ tubes showed large adhesion forces (?5 nN) with extended rupture lengths (up to 500 nm). By contrast, bacteria poorly adhered to yeast cells, emphasizing the important role of the yeast-to-hyphae transition in mediating adhesion to bacterial cells. Analysis of mutant strains altered in cell wall composition allowed us to distinguish the main fungal components involved in adhesion, i.e. Als proteins and O-mannosylations. We suggest that the measured co-adhesion forces are involved in the formation of mixed biofilms, thus possibly as well in promoting polymicrobial infections. In the future, we anticipate that this SCFS platform will be used in nanomedicine to decipher the molecular mechanisms of a wide variety of pathogen-pathogen interactions and may help in designing novel anti-adhesion agents. PMID:24057018
Beaussart, Audrey; Herman, Philippe; El-Kirat-Chatel, Sofiane; Lipke, Peter N; Kucharíková, So?a; Van Dijck, Patrick; Dufrêne, Yves F
Various workers, including T. D. Stewart, claim that the aboriginal Americas were relatively disease-free because of the bering Strait cold-screen, eliminating many pathogens, and the paucity of zoonotic infections because of few domestic animals. Evidence of varying validity suggests that precontact Americns had their own strains of treponemic infections, bacillary and amoebic dysenteries, influenza and viral penumonia and other respiratory diseases, salmonellosis and perhaps other food poisoning, various arthritides, some endoparasites such as the ascarids, and several geographically circumscribed diseases such as the rickettsial verruca (Carrion's disease) and New World leishmaniasis and trypanosomiasis. Questionably aboriginal are tuberculosis and typhus. Accordingly, virtually all the "crowd-type" ecopathogenic diseases such as smallpox, yellow fever, typhoid, malaria, measles, pertussis, polio, etc., appear to have been absent from the New World, and were only brought in by White conquerors and their Black slaves. My hypothesis is that native American medical care systems--especially in the more culturally advanced areas--were sufficiently sophisticated to deal with native disease entities with reasonable competence. But native medical systems could not cope with the "crowd-type" disease imports that struck Indian and Eskimos as "virgin-field" populations. Reanalysis of native population losses through a genocidal combination of diease, war, slavery and attendant cultural disruption by Dobyns, Cook and others strongly suggest that traditiona estimates underplayed the death toll by a factor of the general order of ten. This would make for an immediately pre-contact Indian population of some 90-111 million instead of the tradition 8-11 million. Evidence is growing that Indians may have been no more susceptible to new pathogens that are other "virgin soil" populations, and thus their immune systems need not be considered less effective than those in other people. Present-day high mortality rates in Indians of both continents from infectious disease imports may be more socioeconomic than anything else. PMID:793420
The purpose of the report is to provide information on political issues in health that are important to Minnesota. The report is presented in three sections. The first places Minnesota health issues in a meaningful framework by considering the reasoning b...
Purpose: The external audit of oncologist clinical practice is increasingly important because of the incorporation of audits into national maintenance of certification (MOC) programs. However, there are few reports of external audits of oncology practice or decision making. Our institution (The Cancer Institute, Singapore) was asked to externally audit an oncology department in a developing Asian nation, providing a unique opportunity to explore the feasibility of such a process. Methods and Materials: We audited 100 randomly selected patients simulated for radiotherapy in 2003, using a previously reported audit instrument assessing clinical documentation/quality assurance and medicaldecision making. Results: Clinical documentation/quality assurance, decision making, and overall performance criteria were adequate 74.4%, 88.3%, and 80.2% of the time, respectively. Overall 52.0% of cases received suboptimal management. Multivariate analysis revealed palliative intent was associated with improved documentation/clinical quality assurance (p = 0.07), decision making (p 0.007), overall performance (p = 0.003), and optimal treatment rates (p 0.07); non-small-cell lung cancer or central nervous system primary sites were associated with better decision making (p = 0.001), overall performance (p = 0.03), and optimal treatment rates (p = 0.002). Conclusions: Despite the poor results, the external audit had several benefits. It identified learning needs for future targeting, and the auditor provided facilitating feedback to address systematic errors identified. Our experience was also helpful in refining our national revalidation audit instrument. The feasibility of the external audit supports the consideration of including audit in national MOC programs.
Shakespeare, Thomas P. [North Coast Cancer Institute, Coffs Harbour, Sydney, NSW (Australia) and Cancer Institute (Singapore)]. E-mail: ThomasShakespeare@gmail.com; Back, Michael F. [Cancer Institute (Singapore); Lu, Jiade J. [Cancer Institute (Singapore); Lee, Khai Mun [Cancer Institute (Singapore); Mukherjee, Rahul K. [Cancer Institute (Singapore)
To characterize predictors of impairment in research decision-making capacity, we undertook a direct comparison of schizophrenia/schizoaffective (n= 52), medically ill (diabetic; n= 51), and non-ill (n= 57) subjects. Scores on the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) were correlated with demographic variables and scores on the Positive and Negative Syndrome Scale (PANSS), Mini-Mental State Examination (MMSE), and Short-Form-36 (SF-36). Across diagnoses, cognitive capacity, physical functioning, and a diagnosis of mental illness had the greatest impact on decision-making capacity, with level of education also having an impact. 69–89% of schizophrenia/schizoaffective subjects attained MacCAT-CR subscale scores achieved by almost all comparison (98–100%) and medically ill (94–100%) subjects. Positive, negative, and general psychotic symptoms correlated with poorer scores. Prior research experience, number of queries used during interview, and emotional functioning also predicted MacCAT-CR scores. These data suggest that investigators and IRBs should consider a number of variables, many of which reach across diagnoses, as they decide which populations and individual subjects may require more intensive screening for decisional impairment or educational interventions to improve their abilities to make capable decisions about research participation.
Candilis, Philip J.; Fletcher, Kenneth E.; Geppert, Cynthia M.A.; Lidz, Charles W.; Appelbaum, Paul S.
ABSTRACTObjectives: To investigate whether Chinese adolescents in Hong Kong share similar perceptions with their Western counterparts regarding their capacity for autonomous decision?making, and secondarily whether Chinese parents underestimate their adolescent children's desire and capacity for autonomous decision?making.Method:‘Healthy Adolescents’ and their parents were recruited from four local secondary schools, and ‘Sick Adolescents’ and their parents from the pediatric wards and outpatient
|Fernando Viesca has a 24-year-old son who suffers from Angelman Syndrome, a little known chromosomal disorder that has left him with significant functional deficiencies. When Nando lived at home, his father took care of him full time, thus alleviating any worries about medical care. However, now that Nando lives in a group home, his father is no…
Fernando Viesca has a 24-year-old son who suffers from Angelman Syndrome, a little known chromosomal disorder that has left him with significant functional deficiencies. When Nando lived at home, his father took care of him full time, thus alleviating any worries about medical care. However, now that Nando lives in a group home, his father is no…
The changed circumstances of medical work, raises the question of how socio-economic changes over the last few decades has\\u000a affected the professional socialisation of medical students. This paper explores the career choice motivations of medical\\u000a students, as well as some characteristics of the process of making that choice and their effects on professional socialisation.\\u000a The study was carried out with
Regina Molnár; Tibor Nyári; Anikó Hazag; Adriána Csinády; Péter Molnár
Overwhelming evidence supports the importance of sleep for memory consolidation. Medical students are often deprived of sufficient sleep due to large amounts of clinical duties and university load, we therefore investigated how study and sleep habits influence university performance. We performed a questionnaire-based study with 31 medical students of the University of Munich (second and third clinical semesters; surgery and internal medicine). The students kept a diary (in 30-min bins) on their daily schedules (times when they studied by themselves, attended classes, slept, worked on their thesis, or worked to earn money). The project design involved three 2-wk periods (A: during the semester; B: directly before the exam period--pre-exam; C: during the subsequent semester break). Besides the diaries, students completed once questionnaires about their sleep quality (Pittsburgh Sleep Quality Index [PSQI]), their chronotype (Munich Chronotype Questionnaire [MCTQ]), and their academic history (previous grades, including the previously achieved preclinical board exam [PBE]). Analysis revealed significant correlations between the actual sleep behavior during the semester (MS(diary); mid-sleep point averaged from the sleep diaries) during the pre-exam period and the achieved grade (p = 0.002) as well as between the grades of the currently taken exam and the PBE (p = 0.002). A regression analysis with MS(diary) pre-exam and PBE as predictors in a model explained 42.7% of the variance of the exam grade (effect size 0.745). Interestingly, MS(diary)--especially during the pre-exam period-was the strongest predictor for the currently achieved grade, along with the preclinical board exam as a covariate, whereas the chronotype did not significantly influence the exam grade. PMID:23750895
Genzel, L; Ahrberg, K; Roselli, C; Niedermaier, S; Steiger, A; Dresler, M; Roenneberg, T
In 2002, Belgium saw the enactment of 3 laws concerning euthanasia, palliative care, and patient rights that are likely to affect end-of-life decision making. This report examines trends in the occurrence and decision-making process of end-of-life practices in different patient groups since these legal changes. A large-scale retrospective survey in Flanders, Belgium, previously conducted in 1998 and 2001, was repeated in 2007. Questionnaires regarding end-of-life practices and the preceding decision-making process were mailed to physicians who certified a representative sample (N = 6927) of death certificates. The 2007 response rate was 58.4%. In patient groups in which the prevalence of life-ending drug use without explicit patient request has dropped, performance of euthanasia and assisted suicide has increased. The consistent increase in intensified pain and symptom alleviation was found in all patient groups except cancer patients. In 2007, competent patients were slightly more often involved in the discussion of end-of-life practices than in previous years. Over the years, involvement of the patient in decision making was consistently more likely among younger patients, cancer patients, and those dying at home. Physicians consulted their colleagues more often than in previous years for euthanasia and nontreatment decisions. The euthanasia law and emerging palliative care culture have substantially affected the occurrence and decision making for end-of-life practices in Belgium. Efforts are still needed to encourage shared end-of-life decision making, as some patients would benefit from advance care planning. PMID:21191121
Minors (i.e., those under 18 years of age) hold a tenuous legal position in medical settings. While recent legal authority in numerous jurisdictions affords competent minors the right to consent to medical treatment, the guidelines for assessing competence are often vague or non-existent. In addition, these changes have not adequately addressed the issue of confidentiality, and it is unclear whether
Background Clinically importantmedication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events as well as medication discrepancies or non-adherence with high potential for future harm (potential adverse drug events). Objective The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study sought to determine the effect of a tailored intervention on the occurrence of clinically importantmedication errors after hospital discharge. Design Randomized controlled trial with concealed allocation and blinded outcome assessors. Setting Two tertiary care academic hospitals. Patients Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. Intervention Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. Measurements The primary outcome was the number of clinically importantmedication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable adverse drug events, as well as potential adverse drug events. Results Among 851 participants, 432 (50.8%) experienced 1 or more clinically importantmedication errors; 23% of such errors were judged to be serious, and 2% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential adverse drug events in 253 (29.7%). The intervention did not significantly alter the per-patient number of clinically importantmedication errors (IRR=0.92; 95% CI, 0.77 to 1.10) or adverse drug events (IRR=1.09; CI, 0.86 to 1.39). Intervention patients tended to have fewer potential adverse drug events (IRR=0.80; CI, 0.61 to 1.04). Limitations The characteristics of the study hospitals and participants may limit generalizability. Conclusions Clinically importantmedication errors were present among half of patients after hospital discharge and were not significantly reduced by a health-literacy sensitive, pharmacist-delivered intervention.
Kripalani, Sunil; Roumie, Christianne L.; Dalal, Anuj K.; Cawthon, Courtney; Businger, Alexandra; Eden, Svetlana K.; Shintani, Ayumi; Sponsler, Kelly Cunningham; Harris, L. Jeff; Theobald, Cecelia; Huang, Robert L.; Scheurer, Danielle; Hunt, Susan; Jacobson, Terry A.; Rask, Kimberly J.; Vaccarino, Viola; Gandhi, Tejal K.; Bates, David W.; Williams, Mark V.; Schnipper, Jeffrey L.
The author describes some investigations carried out on a number of insects of medicalimportance in Taiwan (six species of Anopheles, one species of Culex, one of Aëdes, two subspecies of Musca domestica and one species of Cimex) with the object of finding out whether resistance to DDT and BHC had developed among them as a result of the insect-control campaigns which have been in operation in the island since 1948. Of the anophelines, certain strains of A. minimus and A. h. sinensis were found to have a relatively high and statistically significant tolerance to DDT, but whether this can be regarded as developed resistance remains to be ascertained. As to the other insects examined, some strains exhibited statistically significant differences in tolerance to DDT; in certain cases, however, the ancestors of the tolerant strains had never been exposed to DDT, and it has not been possible yet to find an explanation for this phenomenon. No significant difference in susceptibility to ?-BHC was shown by three strains of Cimex hemipterus, two of which had previously been exposed to mixtures of DDT and BHC and one of which had not.
Background Two common southern African mice species, Mastomys coucha and M. natalensis, are widely distributed throughout the subregion and overlap in many areas. They also share a high degree of morphological similarity, making them impossible to distinguish in the field at present. These multimammate mice are documented carriers of serious disease vectors causing Lassa fever, plague and encephalomyocarditis, which coupled to their cohabitation with humans in many areas, could pose a significant health risk. A preliminary study reported the presence of isozyme markers at three loci (GPI-2, PT-2, -3) in one population each of M. coucha and M. natalensis. Two additional populations (from the Vaal Dam and Richards Bay) were sampled to determine the reliability of these markers, and to seek additional genetic markers. Results Fifteen proteins or enzymes provided interpretable results at a total of 39 loci. Additional fixed allele differences between the species were detected at AAT-1, ADH, EST-1, PGD-1, Hb-1 and -2. Average heterozygosities for M. coucha and M. natalensis were calculated as 0.018 and 0.032 respectively, with a mean genetic distance between the species of 0.26. Conclusions The confirmation of the isozyme and the detection of the additional allozyme markers are important contributions to the identification of these two medical and agricultural pest species.
This report describes the application of reference strand-mediated conformational analysis (RSCA), a novel DNA typing technique, for the identification of clinically significant fungal pathogens. RSCA is a heteroduplex-based conformational method which relies on detecting differences in the DNA conformation of heteroduplexes generated in this study by the annealing of different fungal 18S rRNA amplicons to a common fluorescent-labelled reference (FLR). These heteroduplexes are then observed with laser-based instrumentation and computer software to detect differences in the DNA conformation reproducibly. This technique was shown to generate unique and reproducible profiles for the 18S rRNA gene sequences of a number of medicallyimportant fungi, distinguishing different Candida species (C. albicans, C. kefyr, C. dubliniensis, C. lusitaniae, C. guilliermondii, C. tropicalis, C. krusei, C. glabrata, C. sake and C. parapsilosis), and in some cases detecting single nucleotide differences between 18S rRNA sequences. The RSCA technique was further evaluated with 50 human clinical isolates of Candida spp., previously identified by culture techniques, and was shown to identify the isolates correctly. This technique displays enormous potential as an alternative to DNA sequence determination and has the potential to become an automated technique that can be implemented in the routine setting. PMID:12018653
McIlhatton, Brian P; Keating, Caitriona; Curran, Martin D; McMullin, Mary-Frances; Barr, Jack G; Madrigal, J Alejandro; Middleton, Derek
The search for new compounds with antifungal activity is accelerating due to rising yeast and fungal resistance to commonly prescribed drugs. Among the molecules being investigated, plant lectins can be highlighted. The present work shows the potential of six plant lectins which were tested in vitro against yeasts of medicalimportance, Candida albicans, Candida tropicalis, Candida parapsilosis, Cryptococcus gattii, Cryptococcus neoformans, Malassezia pachydermatis, Rhodotorula sp. and Trichosporon sp. Broth microdilution susceptibility testing was performed in accordance with standard protocols to evaluate antifungal activity. Minimum inhibitory concentration (MIC) was determined at 80% yeast growth inhibition, whereas the minimum fungicidal concentration (MFC) was evaluated after making the subcultures of each dilution. Only C. parapsilosis growth was inhibited by the lectins tested. Abelmoschus esculentus lectin showed the highest MIC (0.97 ?g ml(-1)). Lectins from Canavalia brasiliensis, Mucuna pruriens and Clitoria fairchildiana presented the highest MFC at (3.90 ?g ml(-1)). These results encourage further studies with wider yeast strain selections, and open new perspectives for the development of pharmacological molecules. PMID:23161017
The Virtual Medical Record (vMR) is a structured data model for representing individual patient informations1. Our implementation of vMR is based on HL7 Reference Information Model (RIM) v2.13 from which a minimum set of objects and attributes are selected to meet the requirement of a clinical decision support (CDS) rule engine. Our success of mapping local patient data to the vMR model and building a vMR adaptor middle layer demonstrate the feasibility and advantages of implementing a vMR in a portable CDS solution.
Huang, Christine; Noirot, Laura A.; Heard, Kevin M.; Reichley, Richard M.; Dunagan, Wm Claiborne; Bailey, Thomas C.
Despite growing interest in the use of evidence-based treatment practices, adoption of pharmacotherapies for treating substance use disorders (SUDs) remains modest. Using data from telephone interviews with 250 administrators of publicly funded SUD treatment programs, this study estimated a model of adoption of medication assisted treatment (MAT) for SUDs and examined the relative importance of regulatory, cultural, medical resource, patient-level, and funding barriers to MAT implementation. MAT-adopting programs had significantly greater medical resources, as measured by the employment of physicians and nurses, than non-adopting programs. Administrators of non-adopting programs were asked to rate the importance of 18 barriers to MAT implementation. The most strongly endorsed barriers were regulatory prohibitions due to the program’s lack of medical staff, funding barriers to implementing MAT, and lack of access to medical personnel with expertise in delivering MAT. Barriers related to insufficient information about MAT and unsupportive staff attitudes were not widely endorsed. These findings suggest that efforts to promote the implementation of MAT that are inattentive to funding barriers and weaknesses in medical infrastructure may achieve sub-optimal results.
Knudsen, Hannah K.; Abraham, Amanda J.; Oser, Carrie B.
Despite growing interest in the use of evidence-based treatment practices, adoption of pharmacotherapies for treating substance use disorders (SUDs) remains modest. Using data from telephone interviews with 250 administrators of publicly funded SUD treatment programs, this study estimated a model of adoption of medication assisted treatment (MAT) for SUDs and examined the relative importance of regulatory, cultural, medical resource, patient-level, and funding barriers to MAT implementation. MAT-adopting programs had significantly greater medical resources, as measured by the employment of physicians and nurses, than non-adopting programs. Administrators of non-adopting programs were asked to rate the importance of 18 barriers to MAT implementation. The most strongly endorsed barriers were regulatory prohibitions due to the program's lack of medical staff, funding barriers to implementing MAT, and lack of access to medical personnel with expertise in delivering MAT. Barriers related to insufficient information about MAT and unsupportive staff attitudes were not widely endorsed. These findings suggest that efforts to promote the implementation of MAT that are inattentive to funding barriers and weaknesses in medical infrastructure may achieve sub-optimal results. PMID:21371752
Knudsen, Hannah K; Abraham, Amanda J; Oser, Carrie B
In this study, we investigate the impact of an ethical decision-making construct, the ‘perceived importance of an ethical issue’ (PIE) for accounting students in an academic setting. One objective was to test the measure of this construct for generalizability in gauging ethical decision- making. The other objective was to draw inferences on the PIE construct for pedagogical purposes. Using tests
Answer justification refers to the ability of a computer program to explain how or why it arrived at a particular conclusion. This paper presents a new method for automated answer justification that is suitable for use in computer-supported decision aids in medicine which are based on Bayesian classification. The factors most responsible for the relative ordering of posterior probabilities of outcomes are identified by analyzing the prior and conditional probabilities used to generate them. This approach is illustrated using a computer decision aid for stroke classification and is seen to produce understandable and clinically plausible explanations. PMID:3893877
An interactive decision-support system for the prescription of total or partial parenteral nutrition (TPN) is described. The system is applicable to all sizes and ages of patients, from premature infants to adults. Both the physician and the pharmacist are users of the system, with the physician using rule-based safety checks and branching algorithms to make decisions in the prescription process, and the pharmacist receiving the prescription totals electronically in order to complete further calculations needed. Since its introduction, the system appears to have increased the safety of the TPN prescription, saved time, and improved the quality and appropriateness of TPN prescriptions.
Electronic medical records can house patient information gathered over time and at multiple sites, thus they have the potential to increase continuity of care and improve service delivery in a multiclinic system. The New York City Department of Health and Mental Hygiene implemented an electronic medical record system in its 10 sexually transmitted disease clinics during 2004 and 2005. We examine the use of real-time electronic medical record data analyses to evaluate clinical services or program activities and present 3 examples of such analyses that have led to program improvements. Analyses of electronic medical record data have produced changes in clinical practice that in turn have resulted in more effective staff use, increased disease detection, and increased clinic capacity.
Schillinger, Julia A.; Borrelli, Jessica M.; Handel, Shoshanna; Pathela, Preeti; Blank, and Susan
To increase the ability of ultrasonographic (US) technology for the differential diagnosis of solid breast tumors, we describe a novel computer-aided diagnosis (CADx) system using data mining with decision tree for classification of breast tumor to increase the levels of diagnostic confidence and to provide the immediate second opinion for physicians. Cooperating with the texture information extracted from the region
Wen-Jia Kuo; Ruey-Feng Chang; Dar-Ren Chen; Cheng Chun Lee
The present study applied Ajzen's (1985) theory of planned behavior to the explanation of ethical decision making. Nurses in three hospitals were provided with scenarios that depicted inadequate patient care and asked if they would report health professionals responsible for the situation. Study results suggest that the theory of planned behavior can explain a significant amount of variation in the
BACKGROUND: Up to now it has not been systematically investigated in which kind of clinical situations a consultation style based on shared decision making (SDM) is preferred by patients and physicians. We suggest the factorial survey design to address this problem. This method, which so far has hardly been used in health service research, allows to vary relevant factors describing
In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either…
This paper introduces a novel distributed decision support system to help radiologists in the diagnosis of soft tissue tumors (STT). Decision support systems are based on pattern recognition engines that discriminate between benign/malignant character and histological groups with a satisfactory estimated efficiency. This system is based on a distributed architecture with three specialized nodes: Radiologist Visual Interface, Information System and Decision Support Web-services. The visual interface is the radiologists and clinicians' point of access to local and remote STT registers, statistical analysis tools and distributed pattern recognition engines. A location-independent and multi-platform system has been developed in order to connect hospitals and institutions to research useful tools in clinical and laboratory environments. The nodes maintenance and upgrade are automatically controlled by the architecture. This tool will be useful regarding the objective methodology to assist radiologist decision in a new case and will help the education of the new radiologists with no expertise in STT. PMID:17270967
Garcia-Gomez, Juan M; Vidal, Cesar; Vicente, Javier; Marti-Bonmati, Luis; Robles, Montserrat
Group Decision Support Systems (GDSS) are defined and discussed. A GDSS model developed by the author is reviewed in depth for communication of the concepts of GDSS. The model's components are related to health care applications. Questions about unique requirements and level of sophistication in health care applications are explored. What are the differences? What is needed in GDSS software?
In this article, the authors review the development of the Medical Orders for Life-Sustaining Treatment (MOLST) Program and recent landmark legislation in New York State in the context of advance care planning and shared medicaldecision making at the end of life. Social workers are central health care professionals in working with patients, families, practitioners, health care agents, and surrogates
Patricia A. Bomba; Mary Beth Morrissey; David C. Leven
For this report, researchers used hypothetical battle decision situations to study military officers' judgment of probability and relative importance. For the study, 222 correspondents and 72 resident students of the Command and General Staff College read...
Infections caused by yeasts have increased in previous decades due primarily to the increasing population of immunocompromised patients. In addition, infections caused by less common species such as Pichia, Rhodotorula, Trichosporon, and Saccharomyces spp. have been widely reported. This study extensively evaluated the feasibility of sequence analysis of the rRNA gene internal transcribed spacer (ITS) regions for the identification of yeasts of clinical relevance. Both the ITS1 and ITS2 regions of 373 strains (86 species), including 299 reference strains and 74 clinical isolates, were amplified by PCR and sequenced. The sequences were compared to reference data available at the GenBank database by using BLAST (basic local alignment search tool) to determine if species identification was possible by ITS sequencing. Since the GenBank database currently lacks ITS sequence entries for some yeasts, the ITS sequences of type (or reference) strains of 15 species were submitted to GenBank to facilitate identification of these species. Strains producing discrepant identifications between the conventional methods and ITS sequence analysis were further analyzed by sequencing of the D1-D2 domain of the large-subunit rRNA gene for species clarification. The rates of correct identification by ITS1 and ITS2 sequence analysis were 96.8% (361/373) and 99.7% (372/373), respectively. Of the 373 strains tested, only 1 strain (Rhodotorula glutinis BCRC 20576) could not be identified by ITS2 sequence analysis. In conclusion, identification of medicallyimportant yeasts by ITS sequencing, especially using the ITS2 region, is reliable and can be used as an accurate alternative to conventional identification methods.
We characterized the antigenic cross-reactivity of two medicallyimportant North American Loxoxceles species: L. reclusa (native to southeastern US) and L. deserta (native to southwestern US). Dermonecrosis resulting from bites from these two North American spider species are indistinguishable clinically. Polyclonal IgG antivenins directed against L. reclusa and L. deserta were raised in rabbits and used to develop specific enzyme immunoassays (EIAs). Antigenic differences in the two venoms were evaluated as follows: (1) Comparison of the sensitivities and correlation coefficient (R(2)) of anti-L. reclusa (alpha LoxR) and anti-L. deserta antibodies (alpha LoxD) in the detection of varying concentrations of the two venoms; (2) separation and western blot comparison of venom components; (3) protein sequence analysis of L. desertavenom and comparison to the L. reclusa protein sequence analysis present in a US national database; and (4) in vivo evaluation of alpha LoxR and alpha LoxD antivenins in attenuating dermal lesions (rabbit model). Correlation coefficients for alpha LoxR (R(2)=0.99) and alpha LoxD (R(2)=0.99) polyclonal antibodies in the measurements of standard concentrations of venoms were virtually identical. Western blot analysis revealed multiple common bands between the two venoms. Amino acid data (amino acids 1-35, N-terminal) of the active venom components of the two venoms revealed only three non-identical amino acids. alpha LoxR and alpha LoxD antivenins were similarly effective in blocking the development of rabbit skin lesions (ANOVA p<0.05). In summary, L. reclusa and L deserta spider venoms possess several common protein bands as identified by western blot, greater than 90% amino acid sequence identity, and marked antigenic cross-reactivity. PMID:11137541
Gomez, H F; Miller, M J; Waggener, M W; Lankford, H A; Warren, J S
BACKGROUND: Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation\\u000a between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient\\u000a care.\\u000a \\u000a \\u000a OBJECTIVE: To improve medical students’ communication and clinical reasoning and their appreciation of how these skills interrelate\\u000a in medical practice.\\u000a \\u000a \\u000a \\u000a \\u000a DESIGN: In 2003, we conducted
Donna M. Windish; Eboni G. Price; Sarah L. Clever; Jeffrey L. Magaziner; Patricia A. Thomas
The prevalence of medication administration errors continues to be a problem requiring the attention of nurse leaders. In this study the relationship between nurse staffing and the occurrence of medication errors was examined. Using a retrospective design, researchers analyzed secondary data from administrative databases of one hospital containing 801 weekly staffing intervals and 31,080 patient observations. The current study shows that increasing the number of RN hours and decreasing or eliminating LPN hours can be a strategy to reduce medication errors. PMID:23198612
Frith, Karen H; Anderson, E Faye; Tseng, Fan; Fong, Eric A
Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing “Smart Forms” to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions.
To increase the ability of ultrasonographic (US) technology for the differential diagnosis of solid breast tumors, we describe a novel computer-aided diagnosis (CADx) system using data mining with decision tree for classification of breast tumor to increase the levels of diagnostic confidence and to provide the immediate second opinion for physicians. Cooperating with the texture information extracted from the region of interest (ROI) image, a decision tree model generated from the training data in a top-down, general-to-specific direction with 24 co-variance texture features is used to classify the tumors as benign or malignant. In the experiments, accuracy rates for a experienced physician and the proposed CADx are 86.67% (78/90) and 95.50% (86/90), respectively. PMID:11368410
Rationale and ObjectivesThe purpose of this study was to investigate the ability of medical students who had already completed medicine and surgery clerkships to identify life-threatening abnormalities on conventional chest radiographs.
Jac D. Scheiner; Richard B. Noto; Kathleen M. McCarten
An improved Computer Aided Clinical Decision Support System has been developed to classify the tumor and identify the stages\\u000a of the cancer using neural network and presented in this paper. The texture and shape features have been extracted and the\\u000a optimal feature set has been obtained using multiobjective genetic algorithm (MOGA). The multilayer back propagation neural\\u000a network with Ant Colony
Objectives:To discover the current state of opinion and practice among doctors in Victoria, Australia, regarding end-of-life decisions and the legalisation of voluntary euthanasia. Longitudinal comparison with similar 1987 and 1993 studies.Design and participants:Cross-sectional postal survey of doctors in Victoria.Results:53% of doctors in Victoria support the legalisation of voluntary euthanasia. Of doctors who have experienced requests from patients to hasten death,
Studies have shown that adverse drug events are common, expensive, and due to causes that can be remedied by information technologies. At our institution we have developed a physician order entry application and a pharmacy application designed to decrease the risk of such adverse drug events. In this paper, we describe the applications, with attention to the clinical decision support features present in each. We also describe the manner in which the two applications interact. PMID:10384500
Kuperman, G J; Cooley, T; Tremblay, J; Teich, J M; Churchill, W
This study details the processes students use and the information they consider as they confront what is likely to be their\\u000a first major life decision. Over the course of a year, 322 college-bound high school students participated in up to three survey\\u000a sessions in which they described their thinking about college decisions. At each session, students rated the frequency with
Providing semantic web technologies in a medical domain has its obvious advantages. Having distributed services using shared domain vocabularies provides a great impetus for the integration of disparate hospital information systems, as well as the possibility of providing more accurate diagnoses and a well organised knowledge base for sharing, tutoring and researching. Using such disparate systems requires careful consideration both
Nigel Shadbolt; Paul Lewis; Srinandan Dasmahapatra; David Dupplaw; Bo Hu; Hugh Lewis
Aviation disasters cause huge loss of lives and properties. Any densely populated and economically viable country inevitably faces the challenge of efficiently and effectively responding to such disasters. This study supports in-time reaction to aviation disasters from the medical point of view: transferring patients to available hospitals to maximize their survival time. This study first assumes a large aircraft crash
An improved Computer Aided Clinical Decision Support System has been developed to classify the tumor and identify the stages of the cancer using neural network and presented in this paper. The texture and shape features have been extracted and the optimal feature set has been obtained using multiobjective genetic algorithm (MOGA). The multilayer back propagation neural network with Ant Colony Optimization and Particle Swarm Optimization has been used. The accuracy of the proposed system has been verified and found that the accuracy of 99.5% can be achieved. The proposed system can provide valuable information to the physicians in clinical pathology. PMID:20703746
Currently, there are no established guidelines which define the goals, the course content, or the approach to developing a successful medical-nutrition education program. The result has been great variability in the approach to teaching nutrition to medical students. A common concern among medical educators is how to teach all of the material currently known. The obvious outcome of trying to teach the constantly expanding body of facts is an increasing demand and competition for instructional time. In turn, nutrition educators have fallen into the trap of vying for more time and claiming success for their program on the basis of their acquired number of hours of instruction rather than on the demonstrated quality or effectiveness of their program. The purpose of this report is to recommend a set of goals for nutrition training of medical students and to highlight those factors which appear to be most (and least) important to achieving those goals. It is my belief that the primary goal of educating medical students should be to sensitize students to the relevance of nutrition in the prevention and treatment of disease. A secondary goal should be to impart important information about nutrition. Relative to these goals, and based on previous studies and on my experience at the University of Alabama at Birmingham School of Medicine, I believe that two factors are critical to the success of any medical-nutrition education program: 1) demonstrated relevance of the course material to the practice of medicine, and 2) positive role modeling.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7572717
The legal standard for informed consent to medical treatment requires that the consenter be informed, competent, and acting voluntarily. The voluntary requirement of a valid consent was investigated by comparing forty 9- and 10-year-old children and forty 14- and 15-year-old adolescents (both generally presumed to be incapable of voluntary consent) with 47 young adults ranging in age from 21 to
Virginia Commonwealth University developed an enhanced medical student geriattic curriculum that includes required home visits and nursing home visits for second year students (180 per year), an annual Forum on Aging for all first and second year students, and small group exercises. We added 30 hours of basic science material to pre-clinical…
Boling, Peter A.; Willett, Rita M.; Gentili, Angela; Abbey, Linda J.; Lawson, Sonya R.; Schlesinger, Jeanne B.; Meyers, Elizabeth M.
|Virginia Commonwealth University developed an enhanced medical student geriattic curriculum that includes required home visits and nursing home visits for second year students (180 per year), an annual Forum on Aging for all first and second year students, and small group exercises. We added 30 hours of basic science material to pre-clinical…
Boling, Peter A.; Willett, Rita M.; Gentili, Angela; Abbey, Linda J.; Lawson, Sonya R.; Schlesinger, Jeanne B.; Meyers, Elizabeth M.
Most spiders use venom to paralyze their prey and are commonly feared for their potential to cause injury to humans. In North America, one species in particular, Loxosceles reclusa (brown recluse spider, Sicariidae), causes the majority of necrotic wounds induced by the Araneae. However, its distributional limitations are poorly understood and, as a result, medical professionals routinely misdiagnose brown recluse
Erin E. Saupe; Monica Papes; Paul A. Selden; Richard S. Vetter; Corrie Moreau
|To design effective academic health centers for the future, medical leaders must define the competencies needed by tomorrow's physicians, including the ability to manage the uncertainty associated with creating clinical models and the uncertainty associated with managing care delivery. Currently, focus is on the former, but there is increasing…
Fargason, Crayton A., Jr.; Evans, H. Hughes; Ashworth, Carolyn S.; Capper, Stuart A.
Stroke is a medical emergency which requires hospital care. Therapeutic and effective organizative measures, such as thrombolysis and stroke units, are available, but early attention is required, as the benefits are time dependent (therapeutic window). To achieve this objective, a high level of organization and coordination is required between the various steps of care. The chain of attention in acute
The importance of including patient preferences in decisions regarding their care has received increased emphasis over recent years. Medical informatics can play an important role in improving patient-centered care by developing decision support systems to support the inclusion of patient preferences in clinical decision making. However, development of such systems is a complex task that requires the integration of knowledge
Diagnoses made at autopsy are usually yes-no (binary) decisions inferred from clinicopathologic data. A major conceptual problem in determining cause of death is that variables used in classifying some patients may be missing in other patients. A model with too few logical implications will be mathematically incomplete for small data sets; but a model too many implications may be inconsistent with large data sets. We examined the 155 patients autopsied after coronary artery bypass surgery from The Johns Hopkins Hospital autopsy database of 43200 cases. Diagnoses entered on a word processor and transmitted to a minicomputer were solved by the Quine-McCluskey algorithm. Our analysis disclosed that 41% of patients suffered a fatal complication of cardiac surgery; 43% had established surgical complications or unrelated causes of death; and in 17% of cases the cause of death was unexplained. Computerized symbolic logic analysis of medical information is useful in testing the completeness of a proposed set of causes of death.
Neonatal intensive care has been studied from an epidemiological, ethical, medical and even sociological perspective, but little is known about the impact of parental involvement in decision-making, especially in critical cases. We rely here on a comparative, case-based approach to study the parental role in decision-making within two technologically identical but culturally and institutionally different contexts: France and the United
A rule-based expert system, EMERGE, was designed to function in an emergency room setting. EMERGE is implemented in the standard Pascal computer language, is machine-independent, and can operate on a microcomputer. The knowledge base for EMERGE was derived from an existing medical outline known as a criteria map. In this paper, the adaptation of EMERGE to a new knowledge base is described. The new area of application is the diagnosis and management of diabetes mellitus. The rules for this knowledge base were again derived from an existing criteria map.
Abstract Common symptoms associated with HIV disease and its management are often underrecognized and undertreated. A clinical decision support tool for symptom management was developed within the Veterans Health Administration electronic medical record (EMR), aiming at increasing provider awareness of and response to common HIV symptoms. Its feasibility was studied in March to May 2007 by implementing it within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Fifty-six patients and their providers participated in the study. Patients' perceptions of providers' awareness of their symptoms, proportion of progress notes mentioning any symptom(s) and proportion of care plans mentioning any symptom(s) were measured. The clinical decision support tool used portable electronic “tablets” to elicit symptom information at the time of check-in, filtered, and organized that information into a concise and clinically relevant EMR note available at the point of care, and facilitated clinical responses to that information. It appeared to be well accepted by patients and providers and did not substantially impact workflow. Although this pilot study was not powered to detect effectiveness, 25 (93%) patients in the intervention group reported that their providers were very aware of their symptoms versuas 27 (75%) control patients (p = 0.07). The proportion of providers' notes listing symptoms was similar in both periods; however, there was a trend toward including a greater number of symptoms in intervention period progress notes. The symptom support tool seemed to be useful in clinical HIV care. The Veterans Health Administration EMR may be an effective “laboratory” for developing and testing decision supports.
Tsevat, Joel; Justice, Amy C.; Mrus, Joseph M.; Levin, Forrest; Kozal, Michael J.; Mattocks, Kristin; Farber, Steven; Rogers, Michelle; Erdos, Joseph; Brandt, Cynthia; Kudel, Ian; Braithwaite, Ronald
The increasing volume of research by the medical community often leads to increasing numbers of contradictory findings and\\u000a conclusions. Although the differences observed may represent true differences, the results also may differ because of sampling\\u000a variability as all studies are performed on a limited number of specimens or patients. When planning a study reporting differences\\u000a among groups of patients or
Healthcare personnel (HCP) are at risk from occupational exposure to airborne and bloodborne pathogens, and the risk of infection among HCP is greater than among the general population. The aim of the study was to characterize attitudes toward occupational recommended vaccines as well as the perception of risks of occupationally acquired infections. We surveyed 650 medical students to assess their perception of influenza and hepatitis B and their opinions and beliefs about influenza and hepatitis B vaccines. We found differences between pre-clinical and clinical students regarding the uptake of influenza and hepatitis B vaccines, about the chances of being occupationally infected with influenza or hepatitis B, and about the likelihood of suffering from severe side-effects following immunization. Interestingly, the risk perception varied drastically between the two vaccine-preventable diseases hepatitis B and influenza. Medical students rated the probability of contracting hepatitis B due to a work-related exposure and the severity of disease significantly higher than for influenza, and this may be an explanation for the greater acceptance of the hepatitis B vaccine. Furthermore, our findings suggest that medical students are frequently inaccurate in assessing their own risk level, and their specific knowledge about both diseases and the severity of these diseases proved to be unsatisfactory. PMID:24016807
Wicker, Sabine; Rabenau, Holger F; von Gierke, Laura; François, Guido; Hambach, Ramona; De Schryver, Antoon
This paper reports two cases in Hong Kong involving two native Chinese adolescent cancer patients (APs) who were denied their rights to consent to necessary treatments refused by their parents, resulting in serious harm. We argue that the dynamics of the 'AP-physician-family-relationship' and the dominant role Chinese families play in medicaldecision-making (MDM) are best understood in terms of the tendency to hierarchy and parental authoritarianism in traditional Confucianism. This ethic has been confirmed and endorsed by various Chinese writers from Mainland China and Hong Kong. Rather than giving an unqualified endorsement to this ethic, based more on cultural sentimentalism than rational moral reasoning, we warn that a strong familism in MDM, which deprives 'weak' family members of rights, represents the less desirable elements of this tradition, against which healthcare professionals working in this cultural milieu need to safeguard. Specifically for APs, we suggest that parental authority and family integrity should be re-interpreted in terms of parental responsibility and the enhancement of children's interests respectively, as done in the West. This implies that when parents refuse to consent to necessary treatment and deny their adolescent children's right to consent, doctors, as the only remaining advocates of the APs' interest, have the duty to inform the state, which can override parental refusal to enable the doctors to fulfill their professional and moral obligations. In so doing the state exercises its 'parens patriae' power to defend the defenseless in society and the integrity of the medical profession. PMID:18447864
Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three\\u000a periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants.\\u000a Before intervention (Period 1), error rate was 53%, which did not significantly change
Alireza Kazemi; Johan Ellenius; Faramarz Pourasghar; Shahram Tofighi; Aref Salehi; Ali Amanati; Uno G. H. Fors
Diagnostic or therapeutic procedures can lead to breakthrough pain. Thanks to a wise choice of analgesic medication started in due time, this type of pain can be avoided or decreased. The therapeutic options of this preventive approach are presented according to the expected breakthrough pain type and intensity. Specific situations are presented through case discussions. The main pharmacokinetic information needed to prescribe the right analgesic at the right time is summarized in a convenient table. When associated to non-pharmacological measures such as empathy, patient positioning and high quality procedures, preventive analgesia provides patients the best possible relief from breakthrough pain. PMID:23882913
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. An intra-articular corticosteroid injection (IAS), one of the cornerstones of treatment for this disease, is usuaLLy associated with anxiety and pain. A major part of the success in reducing the pain is associated with the level of the child's anxiety even before starting the procedure. This is a case study of a 5 year old girl with JIA, who has been treated with an intra-articular corticosteroid injection to her knee joint. The case study is presented from the point of view of the medical clown, who is an important integral part of the team of the IAS procedure. In this article we will discuss the participation of medical clowns in the treatment of children in general, and in the IAS procedure in particular. The importance of the subject stems from the fact that it has been proven that the presence of medical clowns significantly alleviates the children's anxiety and pain. This study, as well as others on this subject, shows that we should encourage medical clowns as an integraL part of the treatment of children. PMID:22991860
...to be registered as an importer of Morphine (9300), a basic class of controlled...company manufactures a product containing morphine in the United States. The company exports...specifications, the company seeks to import morphine supplied by EDQM to use as...
...to be registered as an importer of Morphine (9300), a basic class of controlled...company manufactures a product containing morphine in the United States. The company exports...specifications, the company seeks to import morphine supplied by EDQM to use as...
...to be registered as an importer of Morphine (9300), a basic class of controlled...company manufactures a product containing morphine in the United States. The company exports...specifications, the company seeks to import morphine supplied by EDQM to use as...
The purpose of this article is to describe a system we developed for importing images on compact discs (CDs) from external imaging departments into our clinical image viewing system, and to report on key metrics regarding veracity of information seen on the CDs. We recommend careful attention to the process of CD importation because of the error rate we have seen. We developed a system and process for importing images on CD into our EMR. The importation system scans the CD for digital imaging and communications in medicine (DICOM) images, and collects all patient information seen. That information is presented to the patient for verification. Once validated, the image data is copied into our clinical viewing system. The importation system includes facilities for collecting instances of incorrect data. About 90% of images are now exchanged between our healthcare enterprise and other entities via CD. Data for the wrong patient (e.g., the wrong CD) is seen in about 0.1% of cases, and a similar number of CDs have data for more than one patient on the CD(s) the patient bring to our facility. Most data are now exchanged via DICOM files. DICOM images burned onto CD media are now commonly used for image exchange. However, applications to import DICOM images are not enough. One must implement a process to assure high confidence that the data imported belongs to the patient you are importing. PMID:21286776
Most spiders use venom to paralyze their prey and are commonly feared for their potential to cause injury to humans. In North America, one species in particular, Loxosceles reclusa (brown recluse spider, Sicariidae), causes the majority of necrotic wounds induced by the Araneae. However, its distributional limitations are poorly understood and, as a result, medical professionals routinely misdiagnose brown recluse bites outside endemic areas, confusing putative spider bites for other serious conditions. To address the issue of brown recluse distribution, we employ ecological niche modeling to investigate the present and future distributional potential of this species. We delineate range boundaries and demonstrate that under future climate change scenarios, the spider's distribution may expand northward, invading previously unaffected regions of the USA. At present, the spider's range is centered in the USA, from Kansas east to Kentucky and from southern Iowa south to Louisiana. Newly influenced areas may include parts of Nebraska, Minnesota, Wisconsin, Michigan, South Dakota, Ohio, and Pennsylvania. These results illustrate a potential negative consequence of climate change on humans and will aid medical professionals in proper bite identification/treatment, potentially reducing bite misdiagnoses. PMID:21464985
Saupe, Erin E; Papes, Monica; Selden, Paul A; Vetter, Richard S
Popular approach to the history of medicine rests on naive assumptions that: 1) only the present state of medical knowledge can be counted as scientific and only those elements of the former knowledge and practice which fitted the body of contemporary science should be regarded by the historians of medicine (presentism); 2) medical sciences, like the other natural sciences, portray natural phenomena as they really are (naturalism); 3) progress in sciences consists of cumulative growth of information and explanation. The twentieth century philosophical critique of science revealed that none of these assumptions were true. Empirical facts, which are taken as a basis for any true knowledge, are dependent on the presumed theories; theories are intertwined into a broader socio-cultural context; theory-changing processes are caused by social factors rather than by the theoretical content. Therefore, it is a common task of historians of medicine and philosophers of science to reveal all theoretical and cultural premises on which our comprehension of the contemporary medicine is founded. PMID:9933889
The discovery linking the genes BRCA1&2 to familial breast cancer played an important role in the clinical practice of geneticists and physicians. The availability of genetic tests for BRCA gene mutations prompted cancer geneticists to give information about genetic risk and to assess many women with a personal or family history of breast or ovarian cancer to inform them of
Louise Bouchard; I. Blancquaert; F. Eisinger; W. D. Foulkes; G. Evans; H. Sobol; C. Julian-Reynier
Cost-effectiveness analyses usually quantify peoples' attitudes towards delayed outcomes using the exponential discount model. The authors examined three assumptions of this model by assessing the time preferences of individuals towards hypothetical health states and calculating implicit annual discount rates. Of a random sample of medical students, house officers, and attending physicians, 121 participated, reflecting a response rate of 81%. The participants considered three temporary events (colostomy, blindness, depression) that were destined to occur at five sequentially distant times in the future (one day, six months, one year, five years, and ten years). The utility of each prospect was measured using two elicitation techniques (standard gamble and categorical scaling), and 1,394 implicit discount rates were calculated. Of all the discount rates, 62.1% equalled zero, 10.0% were less than 0.00, and 15.7% were greater than 0.10. Mean discount rates for relatively proximal time intervals tended to be larger than those for relatively more distant intervals (0.041 vs. 0.025, p < 0.01). Mean discount rates for blindness tended to be smaller than those for colostomy or depression (0.023 vs. 0.039 vs 0.037, respectively, p < 0.005). Hence, peoples' implicit discount rates are not always small positive numbers that are constant over time and the same for all settings. The authors suggest that the conventional exponential discount model may not fully characterize the time preferences held by individuals. PMID:8412549
Previous research has found that American patients strongly believe that more testing and more treatment lead to better outcomes and, to a lesser extent, that newer treatments are more effective. We conducted five focus groups with privately insured, healthy, middle-aged Americans (n?=?43) to explore these apparent preferences. Contrary to previous research, an unexpected distinction emerged. Participants placed enormous value on testing and screening, reacting with hostility to guidelines recommending less of either. However, they were suspicious of overmedication. The wariness of pharmaceuticals and enthusiasm for testing and screening both appear to reflect participants’ efforts to take responsibility for their health. But recommendations to test and screen less conflicted with their active, engaged, information-seeking roles. Nonetheless, given patients’ concerns about overuse of pharmaceuticals, we maintain that they can learn to understand the connections between over-testing and over-treatment, and can actively choose to do less. We close with suggestions about how treatment guidelines can better communicate these connections to patients. Our findings cannot necessarily be generalized beyond privately-insured, healthy, middle-aged Americans. But because we found that, among these individuals, attitudes towards pharmaceuticals differ from attitudes towards testing and screening, we maintain that future research should also distinguish among and compare attitudes towards different types of medical interventions.
The authors describe a polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method targeting the 18S rRNA gene for the species detection of medicallyimportant trematode infecting fish and oysters, and suggest that this PCR-RFLP method based on a specific Tre-18 primer and the restriction enzymes, Acc1, Ava2, Msp1, and Hinf1, is useful for the detection of parasites in aquatic food. PMID:23379283
The Department of Veterans Affairs is developing, testing and evaluating the benefits of physicians' workstations as an aid to medical data capture in an outpatient clinic setting. The physician's workstation uses a graphical user interface to aid the clinician in recording encounter data. Various input devices including keyboard, mouse, pen, voice, barcode reader, and tablet are available on the workstations, and user preferences will be examined. Access to general services such as electronic mail and reference databases is also available. The workstation provides a wide variety of patient specific data from the hospital information system, including image data. The single data collection process by the clinician will also provide data for the cost recovery process. PMID:7949987
Dayhoff, R; Kirin, G; Pollock, S; Miller, C; Todd, S
The purpose of this article is to describe a system we developed for importing images on compact discs (CDs) from external\\u000a imaging departments into our clinical image viewing system, and to report on key metrics regarding veracity of information\\u000a seen on the CDs. We recommend careful attention to the process of CD importation because of the error rate we have
When a patient with multiple, complicated conditions is admitted to a hospital and risky procedures are performed that result in adverse outcomes, the difficulties inherent in determining whether and when a preventable medical error has occurred must be addressed. This article analyzes the case of a 40-year-old woman with a history of chronic aortic dissection and pericardial effusion who was admitted to a teaching hospital with unilateral swelling of her left breast and arm accompanied by dyspnea. During her hospitalization, the patient developed multiple complications from the diagnostic and therapeutic procedures that were performed. The authors argue that this case illustrates some limitations of routinely undertaking time-consuming and costly reviews, or "root-cause analyses," as a patient safety strategy when they are unlikely to reveal remediable "errors" or to suggest better systems of care that will prevent errors. The ability to establish causality through post hoc reviews is the linchpin in the recommendation for widespread adoption of error reporting and reviews. When causality is not established, it is impossible to know whether any changes adopted as a result of the reviews will be effective. This case, in which the causal pathways to the adverse events are very uncertain, may be much more typical than the egregious errors featured in a classic root-cause analysis. The authors recommend that the relative merits of this approach to patient safety be compared with other proven, cost-effective interventions to improve quality, such as appropriate treatment of myocardial infarction or depression, before scarce resources and enormous human capital are allocated for widespread implementation. PMID:12204016
Medical end-of-life decisions, defined as end-of-life practices with a potential or certain life-shortening effect, precede almost 50% of deaths in Western countries, and receive ample medical-ethical attention. This systematic review aims to detect whether there are differences in the prevalence of medical end-of-life decisions in 'vulnerable' patient groups. In 2009, five major databases were scrutinized for publications containing original data on the prevalence of euthanasia/physician-assisted suicide, life-ending without explicit patient request, intensified symptom alleviation, non-treatment decisions and palliative sedation by social factors (eg age, gender and SES). Heterogeneous findings were pooled using a random effects model. We identified 6377 papers of which 51 papers were selected, involving over 1.09 million patients. Most publications reported the prevalence of non-treatment decisions. The most studied social factors were age and gender. Among patients older than eighty years, non-treatment decisions occurred more frequently compared with younger patients, while intensified symptom alleviation, palliative sedation, euthanasia/physician-assisted suicide and life-ending without explicit request were practiced less often. Similar patterns of association, although less strong, were found for female patients compared with males and those with lower levels of education versus more highly-educated patients. We conclude that the administration of medication with a potential or certain life-shortening effect seemed generally to be practiced less often among the elderly, females and less well-educated patients compared with younger, male or more educated patients, while decisions that include the withdrawal or withholding of treatments seem to be more common in these groups. Further studies should focus on investigating whether these differences reflect less than optimal end-of-life care for specific patient groups. PMID:22401644
Rietjens, Judith A C; Deschepper, Reginald; Pasman, Roeline; Deliens, Luc
This paper addresses the question 'what are the variables influencing social interactions and learning during Authentic Early Experience (AEE)?' AEE is a complex educational intervention for new medical students. Following critique of the existing literature, multiple qualitative methods were used to create a study framework conceptually orientated to a socio-cultural perspective. Study participants were recruited from three groups at one UK medical school: students, workplace supervisors, and medical school faculty. A series of intersecting spectra identified in the data describe dyadic variables that make explicit the parameters within which social interactions are conducted in this setting. Four of the spectra describe social processes related to being in workplaces and developing the ability to manage interactions during authentic early experiences. These are: (1) legitimacy expressed through invited participation or exclusion; (2) finding a role-a spectrum from student identity to doctor mindset; (3) personal perspectives and discomfort in transition from lay to medical; and, (4) taking responsibility for 'risk'-moving from aversion to management through graded progression of responsibility. Four further spectra describe educational consequences of social interactions. These spectra identify how the reality of learning is shaped through social interactions and are (1) generic-specific objectives, (2) parallel-integrated-learning, (3) context specific-transferable learning and (4) performing or simulating-reality. Attention to these variables is important if educators are to maximise constructive learning from AEE. Application of each of the spectra could assist workplace supervisors to maximise the positive learning potential of specific workplaces. PMID:23212811
Yardley, Sarah; Brosnan, Caragh; Richardson, Jane; Hays, Richard
World markets for used equipment are important, but some of the most basic facts about them-such as their size, the best markets, and national laws and regulations that affect such trade-are either nonexistent or difficult to come by. This completely revi...
Radiolabeling studies were employed to investigate the influence of structure on the efficiency of surface functionalization for poly(acrylic acid)-coated shell crosslinked nanoparticles (SCKs) with two types of amine-terminated DOTA chelators. An intricate interplay between the chemical and physical properties of both the DOTA derivative and the SCK nanostructures was revealed, demonstrating the importance of structural control.
Xu, Jinqi; Sun, Guorong; Rossin, Raffaella; Hagooly, Aviv; Li, Zicheng; Fukukawa, Ken-ichi; Messmore, Benjamin W.; Moore, Dennis A.; Welch, Michael J.; Hawker, Craig J.; Wooley, Karen L.
Diagnoses made at autopsy are usually yes-no (binary) decisions inferred from clinicopathologic data. A major conceptual problem in determining cause of death is that variables used in classifying some patients may be missing in other patients. A model with too few logical implications will be mathematically incomplete for small data sets; but a model with too many implications may be inconsistent with large data sets. We examined the 155 patients autopsied after coronary artery bypass surgery from The Johns Hopkins Hospital autopsy data base of 43,200 cases. Diagnoses entered on a word processor and transmitted to a minicomputer were solved by the Quine-McCluskey algorithm. Our analysis disclosed that 41% of patients suffered a fatal complication of cardiac surgery; 43% had established surgical complications or unrelated causes of death; and in 17% of cases the cause of death was unexplained. Computerized symbolic logic analysis of medical information is useful in testing the completeness of a proposed set of causes of death. PMID:6336306
This study was conducted to document the extent to which flow depends on valve position in relation to head-pressure reference. Medtronic PS Medical Delta valves (contour model, performance levels 0.5, 1.0, 1.5, and 2.0) were studied in a bench test designed to evaluate flow rates with respect to valve position in relation to the head-pressure reference postion. The valves were connected to an "infinite" reservoir by the standard inlet catheter. An initial head (proximal) pressure was selected for each valve based on package insert data. The position of the inlet catheter tip was fixed at this starting head pressure, thus making the inlet catheter tip position the reference for relative head pressures on the valve assembly. When the valve body is positioned above this level, the effective head pressure is lowered, and when the valve body is positioned below this level, the effective head pressure is raised. Flow was established with the siphon control portion of the valve body located on the same horizontal level as the inlet catheter tip (the reference head pressure or "0" position). A standard silastic catheter was attached to the outlet of the valve, and its length was fixed at 50 cm for all valves (-50 cm H(2)0). The distal end of the outlet catheter was connected to a fraction collector, and 1-minute samples (five replicates) were collected for gravimetric determination of flow rate. The valve assembly was then moved in 1-cm increments through the range of 4 cm above to 8 cm below the head-pressure reference position. Samples were collected from each position (4 cm to -8 cm) relative to the inlet catheter tip. Flow rate, in milliliters/hour, was plotted against both relative position (4 cm to -8 cm) and absolute head pressure (in centimeters of water). Each of the valves tested was shown to have a linear relationship between flow and position relative to the inlet catheter tip (or absolute head pressure). The average increase in flow per centimeter of displacement of valve from catheter tip was 16.5 ml/hr/cm (range 14.4-17.6 ml/hr/cm). Once the inlet catheter tip is fixed in position, it serves as a pressure reference. Movement of the valve above this level results in a net decrease in effective head pressure, and movement below this position results in a net increase in effective head pressure. Thus, the positioning of shunt valves in locations different from this pressure reference position should be performed only with the knowledge that significant increases in outflow rate may occur when the valve body is positioned lower than the inlet catheter tip. This increase in outflow rate is not the result of siphoning or a defect in the antisiphon device but instead the result of a net increase in effective head pressure. PMID:16918214
Francel, P C; Stevens, F A; Tompkins, P; Pollay, M
This study reports the design and successful implementation of a decision support system for use by a multi-purpose health worker or in any situation where there is no immediate pediatric or neonatal care. Furthermore to aid in future decision making and service deployment as also for state of health evaluation and administration the decision support system is augmented by a
Herpotrichiellaceous black yeasts and relatives comprise severe pathogens flanked by nonpathogenic environmental siblings. Reliable identification by conventional methods is notoriously difficult. Molecular identification is hampered by the sequence variability in the internal transcribed spacer (ITS) domain caused by difficult-to-sequence homopolymeric regions and by poor taxonomic attribution of sequences deposited in GenBank. Here, we present a potential solution using short barcode identifiers (27 to 50 bp) based on ITS2 ribosomal DNA (rDNA), which allows unambiguous definition of species-specific fragments. Starting from proven sequences of ex-type and authentic strains, we were able to describe 103 identifiers. Multiple BLAST searches of these proposed barcode identifiers in GenBank revealed uniqueness for 100 taxonomic entities, whereas the three remaining identifiers each matched with two entities, but the species of these identifiers could easily be discriminated by differences in the remaining ITS regions. Using the proposed barcode identifiers, a 4.1-fold increase of 100% matches in GenBank was achieved in comparison to the classical approach using the complete ITS sequences. The proposed barcode identifiers will be made accessible for the diagnostic laboratory in a permanently updated online database, thereby providing a highly practical, reliable, and cost-effective tool for identification of clinically important black yeasts and relatives.
The treatment of brain tumors in very young children poses both a therapeutic challenge and a bioethical quandary. The administration of craniospinal radiation after surgery offers the greatest chance for cure but causes severe neurocognitive damage. As a result, current practice does not offer parents the option of full-dose post-operative craniospinal radiation. Some may regard this approach as inappropriate medical paternalism, while others may consider it an example of responsible therapeutics. Evaluation of this dilemma reveals principles which can guide clinicians in determining which treatment options to present to their patients or surrogates, in the context of shared medicaldecision-making.
Mass media health communication has enormous potential to drastically alter how health-related information is disseminated and obtained by different populations. However, there is little evidence regarding the influence of media channels on health decision-making and medical advice-seeking behaviors among the Hispanic population. The Pew 2007 Hispanic Healthcare Survey was used to test the hypothesis that the amount of mass media
Recent works [Epstein S, Rauzy A. Can we trust PRA? Reliab Eng Syst Safety 2005; 88:195–205] have questioned the validity of traditional fault tree\\/event tree (FTET) representation of probabilistic risk assessment problems. In spite of whether the risk model is solved through FTET or binary decision diagrams (BDDs), importance measures need to be calculated to provide risk managers with information
Background Limited data exist on the impact of living kidney donation on the donor-recipient relationship. Purpose of this study was to explore motivations to donate or accept a (living donor) kidney, whether expected relationship changes influence decision making and whether relationship changes are actually experienced. Methods We conducted 6 focus groups in 47 of 114 invited individuals (41%), asking retrospectively about motivations and decision making around transplantation. We used qualitative and quantitative methods to analyze the focus group transcripts. Results Most deceased donor kidney recipients had a potential living donor available which they refused or did not want. They mostly waited for a deceased donor because of concern for the donor’s health (75%). They more often expected negative relationship changes than living donor kidney recipients (75% vs. 27%, p?=?0.01) who also expected positive changes. Living donor kidney recipients mostly accepted the kidney to improve their own quality of life (47%). Donors mostly donated a kidney because transplantation would make the recipient less dependent (25%). After transplantation both positive and negative relationship changes are experienced. Conclusion Expected relationship changes and concerns about the donor’s health lead some kidney patients to wait for a deceased donor, despite having a potential living donor available. Further research is needed to assess whether this concerns a selected group.
In some cases, determination of blood alcohol level is very important. The alcohol level at the time of an event, can affect the court decision and may lead to aggravate the penalty or on the contrary an acquittal. In this article, a criminal action, in one of Turkish High Criminal Court is examined. The case was about the death of a drunk person who had fallen down from the window of his girl friend's house which is on the third floor of an apartment. This person's parent applied to public prosecutor saying that their child did not fall down but was murdered by his girl friend. During this trial, in the victim's autopsy, no alcohol detected in blood in contrast with his girl friend's testimony. Because of this contradiction, a reasonable doubt has emerged that she was the murderer in this suspicious death. However, in the further stages of trial, the reasons of no alcohol detection in the autopsy is investigated. In the basis of this case, the importance and techniques of alcohol detection in blood is discussed with literature. PMID:11705087
To date, no single reported DNA extraction method is suitable for the efficient extraction of DNA from all fungal species. The efficiency of extraction is of particular importance in PCR-based medical diagnostic applications where the quantity of fungus in a tissue biopsy may be limited. We subjected 16 medically relevant fungi to physical, chemical and enzymatic cell wall disruption methods which constitutes the first step in extracting DNA. Examination by light microscopy showed that grinding with mortar and pestle was the most efficient means of disrupting the rigid fungal cell walls of hyphae and conidia. We then trialled several published DNA isolation protocols to ascertain the most efficient method of extraction. Optimal extraction was achieved by incorporating a lyticase and proteinase K enzymatic digestion step and adapting a DNA extraction procedure from a commercial kit (MO BIO) to generate high yields of high quality DNA from all 16 species. DNA quality was confirmed by the successful PCR amplification of the conserved region of the fungal 18S small-subunit rRNA multicopy gene. PMID:16099520
There are no currently Food and Drug Administration-approved or proven off-label treatments for the frontotemporal dementias (FTD). Clinicians, care-givers, and patients struggle regularly to find therapeutic regimens that can alleviate the problematic behavioral and cognitive symptoms associated with these devastating conditions. Success is “hit or miss” and the lessons learned are largely anecdotal to date. Drug discovery in this area has been largely hampered by the heterogeneous clinical presentations and pathological phenotypes of disease that represent significant obstacles to progress in this area. Biologically, plausible treatment strategies include the use of antidepressants (selective serotonin reuptake inhibitors or serotonin-specific reuptake inhibitor and monoamine oxidase inhibitors), acetylcholinesterase inhibitors, N-methyl-D-aspartic acid antagonists, mood stabilizers, antipsychotics, stimulants, antihypertensives, and agents that may ameliorate the symptoms of parkinsonism, pseudobulbar affect, and motor neuron disease that can often coexist with FTD. These medications all carry potential risks as well as possible benefits for the person suffering from FTD, and a clear understanding of these factors is critical in selecting an appropriate therapeutic regimen to maximize cognition and daily functions, reduce behavioral symptoms, and alleviate caregiver burden in an individual patient. The role of the caregiver in tracking and reporting of symptoms and the effects of individual therapeutic interventions is pivotal in this process. This manuscript highlights the importance of establishing an effective therapeutic partnership between the physician and caregiver in the medical management of the person suffering from FTD.
...Issue Permits for the Importation of Fresh Mango Fruit From Pakistan Into the Continental...the continental United States of fresh mango fruit from Pakistan. Based on the findings...noxious weeds via the importation of fresh mango fruit from Pakistan. DATES:...
...Importation of Fresh False Coriander From Panama Into the Continental United States AGENCY...United States of fresh false coriander from Panama. Based on the findings of a pest risk...importation of fresh false coriander from Panama. EFFECTIVE DATE: June 18, 2010....
The goal of the current investigation was to determine how jurors may be influenced by elderly victim/witnesses. Stereotypes of elderly victim/witnesses were hypothesized to differentially impact jurors' perceptions and decisions. Participants (255 college and 229 community members who were jury-eligible) read a trial summary describing the aggravated assault of a man. The described case hinged on the victim's eyewitness identification of the defendant. The description of the victims was varied in order to examine five types of victim/witnesses: (1) a generic adult victim, described as being 31 years of age, (2) a generic elderly witness, described as being 66 years of age, (3) a 66-year-old senior citizen described to elicit the vulnerable-senior stereotype, (4) a 66-year-old grandfather, and (5) a 66-year-old statesman. Contrary to expectations, no significant differences were found between the college and community samples. Further, ratings of the victims' believability did not vary as a function of the different victim types. However, verdict differences were found for the different victim types. The proportion of guilty verdicts awarded in the statesman condition was significantly higher than those awarded when the victim was a generic adult, senior citizen, or grandfather. A significant difference was also found between the vulnerable senior citizen and the generic elderly case, with the generic elderly victim receiving a greater proportion of guilty verdicts than the vulnerable senior citizen. PMID:10439725
Objective To explore physicians' thoughts and considerations of participation in medicaldecision making by hospitalised elderly patients. Design A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire. Setting and participants The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients. Results Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medicaldecision making. Two main categories were found: ‘being challenged’ by this patient group and ‘being a small part of the healthcare production machine’. Both categories were explained by the core category ‘lacking in time’. The reasons for the feeling of ‘being challenged’ were explained by the subcategories ‘having a feeling of incompetence’, ‘having to take relatives into consideration’ and ‘having to take cognitive decline into account’. The reasons for the feeling of ‘being a small part of the healthcare production machine’ were explained by the subcategories ‘at the mercy of routines’ and ‘inadequate remuneration system’, both of which do not favour elderly patients with multimorbidity. Conclusions Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medicaldecision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.
Hellstrom, Ingrid; Andersson, Lars; Friedrichsen, Maria
Background Much of the research on decision-making in health care has focused on consultation outcomes. Less is known about the process by which clinicians and patients come to a treatment decision. This study aimed to quantitatively describe the behaviour shown by doctors and patients during primary care consultations when three types of decision aids were used to promote treatment decision-making in a randomised controlled trial. Methods A video-based study set in an efficacy trial which compared the use of paper-based guidelines (control) with two forms of computer-based decision aids (implicit and explicit versions of DARTS II). Treatment decision concerned warfarin anti-coagulation to reduce the risk of stroke in older patients with atrial fibrillation. Twenty nine consultations were video-recorded. A ten-minute 'slice' of the consultation was sampled for detailed content analysis using existing interaction analysis protocols for verbal behaviour and ethological techniques for non-verbal behaviour. Results Median consultation times (quartiles) differed significantly depending on the technology used. Paper-based guidelines took 21 (19–26) minutes to work through compared to 31 (16–41) minutes for the implicit tool; and 44 (39–55) minutes for the explicit tool. In the ten minutes immediately preceding the decision point, GPs dominated the conversation, accounting for 64% (58–66%) of all utterances and this trend was similar across all three arms of the trial. Information-giving was the most frequent activity for both GPs and patients, although GPs did this at twice the rate compared to patients and at higher rates in consultations involving computerised decision aids. GPs' language was highly technically focused and just 7% of their conversation was socio-emotional in content; this was half the socio-emotional content shown by patients (15%). However, frequent head nodding and a close mirroring in the direction of eye-gaze suggested that both parties were active participants in the conversation Conclusion Irrespective of the arm of the trial, both patients' and GPs' behaviour showed that they were reciprocally engaged in these consultations. However, even in consultations aimed at promoting shared decision-making, GPs' were verbally dominant, and they worked primarily as information providers for patients. In addition, computer-based decision aids significantly prolonged the consultations, particularly the later phases. These data suggest that decision aids may not lead to more 'sharing' in treatment decision-making and that, in their current form, they may take too long to negotiate for use in routine primary care.
Kaner, Eileen; Heaven, Ben; Rapley, Tim; Murtagh, Madeleine; Graham, Ruth; Thomson, Richard; May, Carl
Despite notions that patients are now playing a more proactive role in directing their own health care, our study of breast cancer patients considering adjuvant therapy indicates that, at least for a life-threatening illness, patients still rely heavily on their physicians to make treatment decisions. Out of 100 patients, 80.0% accepted their physician's primary treatment recommendation. Using behavioral decision-making theory
Medical decisional capacity (DC) refers to the ability to understand, appreciate, and make meaningful decisions about one's health. This is an important construct for children living with HIV whose involvement in their medical care has important implications for disease management. In this study, we assessed the relationship among DC, developmental stage, intellectual ability, and social–emotional functioning of children with and
...Fresh Cape Gooseberry Fruit With Husks From Chile AGENCY: Animal and Plant Health Inspection...Physalis peruviana L.) with husks from Chile. Based on the findings of a pest risk...importation of fresh Cape gooseberry fruit from Chile. DATES: Effective Date: December...
Purpose – Despite the increasing volume of scholarly work in international advertising, media selection has received very little attention. This study seeks to address three fundamental issues in media selection for non-domestic markets: the relative importance of cultural factors, the relationships between organization structure, and the relative weight that executives place on cultural and non-cultural factors in their media selection,
Purpose – With brands being an important source of competitive advantage, knowledge of branding is needed to inform their management. After reviewing the literature, the article aims to report the findings of a case study that investigated the role of branding in the industrial purchase of agricultural tractors in the UK. The study's overall conclusion is that branding can play
Keith Walley; Paul Custance; Sam Taylor; Adam Lindgreen; Martin Hingley
This study is the first study that provides useful guidelines to clinical microbiologists and technicians on the usefulness of full 16S rRNA sequencing, 5??end 527?bp 16S rRNA sequencing and the existing MicroSeq full and 500 16S rDNA bacterial identification system (MicroSeq, Perkin?Elmer Applied Biosystems Division, Foster City, California, USA) databases for the identification of all existing medicallyimportant anaerobic bacteria. Full and 527?bp 16S rRNA sequencing are able to identify 52–63% of 130 Gram?positive anaerobic rods, 72–73% of 86 Gram?negative anaerobic rods and 78% of 23 anaerobic cocci. The existing MicroSeq databases are able to identify only 19–25% of 130 Gram?positive anaerobic rods, 38% of 86 Gram?negative anaerobic rods and 39% of 23 anaerobic cocci. These represent only 45–46% of those that should be confidently identified by full and 527?bp 16S rRNA sequencing. To improve the usefulness of MicroSeq, bacterial species that should be confidently identified by full and/or 527?bp 16S rRNA sequencing but not included in the existing MicroSeq databases should be included.
Woo, Patrick C Y; Chung, Liliane M W; Teng, Jade L L; Tse, Herman; Pang, Sherby S Y; Lau, Veronica Y T; Wong, Vanessa W K; Kam, Kwok-ling; Lau, Susanna K P; Yuen, Kwok-Yung
We analyze the phylogeny of the medicallyimportant and taxonomically unresolved viper genus Echis using four mitochondrial gene fragments. The results show that the populations of the genus fall into four main clades: the Echis carinatus, E. coloratus, E. ocellatus and E. pyramidum groups. The E. pyramidum and E. coloratus groups are sister taxa but the interrelationships of this clade and the E. ocellatus and E. carinatus groups are unresolved. The initial divergence of the genus appears to coincide with the collision between Afro-Arabia and Eurasia, and that between the E. coloratus and E. pyramidum clades appears to be associated with the opening of the Red Sea. Later land connections between Africa and Arabia may have contributed to shaping the distribution of the E. pyramidum complex. The present distribution of E. carinatus may be the result of range expansion from southern India. Taxonomically, our results provide molecular evidence for the validity of Echis omanensis, E. khosatzkii, E. borkini and E. jogeri, for the presence of unsuspected genetic diversity within the E. pyramidum complex in eastern Africa, and for the conspecificity of E. carinatus and E. multisquamatus. The status of E. leucogaster remains to be confirmed. PMID:19666129
Pook, Catharine E; Joger, Ulrich; Stümpel, Nikolaus; Wüster, Wolfgang
This paper describes an interactive medical knowledge assistant that can help a doctor or a patient in making important health related decisions. The system is Web based and consists of several modules, including a medical knowledge base, a doctor interface module, patient interface module and a the main module of the medical knowledge assistant. The medical assistant is designed to help interpret the fuzzy data using rough sets approach. The patient interface includes sub-system for real time monitoring of patients' health parameters and sending them to the main module of the medical knowledge assistant.
Each individual U.S. Air Force, Army, and Navy Surgeon General has integrated oversight of global medical supplies and resources using the Joint Medical Asset Repository (JMAR). A Business Intelligence system called the JMAR Executive Dashboard Initiative (JEDI) was developed over a three-year period to add real-time interactive data-mining tools and executive dashboards. Medical resources can now be efficiently reallocated to military, veteran, family, or civilian purposes and inventories can be maintained at lean levels with peaks managed by interactive dashboards that reduce workload and errors. PMID:17947142
Sloane, Elliot B; Rosow, Eric; Adam, Joe; Shine, Dave
An instructional module on decisionmaking and management science is presented as part of an educational program for emergency medical services (EMS) systems administration and planning. The program consists of 23 such modules, which can be adapted to a va...
Purpose: To analyze the effectiveness of the American Red Cross Emergency Response Course (ARC ERC) in improving decision?making skills of physical therapists (PTs) and third semester clinical doctorate student physical therapists (SPTs) when assessing acute sports injuries and medical conditions. Methods: An existing questionnaire was modified, with permission from the original authors of the instrument. The questionnaire was administered to PTs and SPTs before the start of and immediately after the completion of 5 different ARC ERCs. The overall percentages of “Appropriate” responses for the 17 case scenarios were calculated for each participant for the pre?and post?tests. Participants also rated their perceived level of preparedness for managing various conditions using a 5?point Likert Scale (ranging from Prepared to Unprepared). The overall percentage of “Prepared/Somewhat Prepared” responses for the 16 medical conditions was calculated for each participant for the pre?and post?tests. In addition, mean Likert scale scores were calculated for level of perceived preparedness for each of the 16 medical conditions. Paired t?tests, calculated with SPSS 20.0, were used to analyze the data. Results: 37 of 37 (100.0%) of eligible PTs and 45 of 48 (93.8%) of eligible SPTs completed the pre? and post?test questionnaires. The percentage of “Appropriate” responses for all 17 cases in the aggregate (PTs: 76.8% pre?test, 89.0% post?test; SPTs: 68.5%, 84.3%), as well as the percentage of “Prepared/Somewhat Prepared” responses for all conditions in the aggregate (PTs: 67.5%, 96.5%; SPTs: 37.1%, 90.6%) were significantly different from pre?test to post?test (P = .000). There was also a significant difference (P < .05) in the mean overall preparedness Likert scale scores from pre?test to post?test for each medical condition for the SPT's, and 15 of the 16 medical conditions (muscle strains: P = .119) for the PTs. Conclusions: The ARC ERC appears to be effective in improving both PTs' and SPTs' decision?making skills related to acute sports injuries and medical conditions, as both “Appropriate” responses and perceived level of preparedness improved. Level of Evidence: Level 3
Cross, Patrick Stephen; Hauer, Patrick L.; Blom, Heather; Burcham, Jared; Myers, Amanda K.; Grimsrud, Casey
Medication errors cause substantial harm to patients. We need good methods for counting errors, and we need to know how errors defined in different ways and ascertained by different methods are related to the harm that patients suffer. As errors arise within the complex and poorly designed systems of hospital and primary care, analysis of the factors that lead to error, for example by failure mode and effects analysis, may encourage better designs and reduce harms. There is almost no information on the best ways to train prescribers to be safe or to design effective computerized decision support to help them, although both are important in reducing medication errors and should be investigated. We also need to know how best to provide patients with the data they need to be part of initiatives for safer prescribing. PMID:22360355
Medication errors cause substantial harm to patients. We need good methods for counting errors, and we need to know how errors defined in different ways and ascertained by different methods are related to the harm that patients suffer. As errors arise within the complex and poorly designed systems of hospital and primary care, analysis of the factors that lead to error, for example by failure mode and effects analysis, may encourage better designs and reduce harms. There is almost no information on the best ways to train prescribers to be safe or to design effective computerized decision support to help them, although both are important in reducing medication errors and should be investigated. We also need to know how best to provide patients with the data they need to be part of initiatives for safer prescribing.
Objectives: Only half of consultants' medical recommendations are implemented. We created a tool that lets referring providers review and implement electronic recommendations made by consultants, with the hypothesis that facilitation with our tool could improve implementation. Measurements: The tool was piloted among geriatrics consultants and hospitalists. Pre-post evaluation was done with control (before pilot; N 20) and intervention (after pilot;
GREG ABERNATHY; SIU L. HUI; CAROL KEMPF; MICHAEL WEINER
|A medical school course integrating basic science and clinical issues consists of 13 problem-based learning exercises, each exploring a clinical case. Using networked terminals in specially-designed small-group rooms, students progress through cases with a faculty facilitator. Users cite access to better images, accountability, and juxtaposition…
In this paper, we examine the practice of foregoing necessary medical care in a population of young adult Ecstasy users. The objectives of the paper are to (1) investigate how the failure to receive needed medical care is related to drug-related outcomes, and (2) identify factors that are associated with receiving versus foregoing needed medical care. Face-to-face, computer-assisted, structured interviews were conducted with 283 active young adult Ecstasy users in Atlanta, Georgia between August 2002 and October 2007. Study participants were recruited using a targeted sampling approach. Results indicated that almost one-third of the young adult Ecstasy users interviewed did not receive the medical care that they needed during the preceding year. Foregoing such care was associated with a variety of adverse drug-related outcomes, including experiencing a greater number of negative effects from using Ecstasy, experiencing a larger number of drug dependency symptoms, a greater likelihood of ever having binged on Ecstasy, and a greater likelihood of being classified as a “high end” polydrug abuser. Several factors were found to be associated with a greater tendency not to receive the medical care they needed, including race (not being African American), educational attainment (having completed at least high school), self-identification as belonging to the lowest socioeconomic status grouping, low self-esteem, and having experienced sexual abuse during one’s formative years.
In the Netherlands, the practice of life-termination by physicians is still subject to the penal code and yet, since the seventies\\u000a euthanasia and physician assisted death are continuing to occur more openly; this development is supported by public opinion,\\u000a the majority of doctors, and in jurisprudence. Requirements for prudent practice have been compiled in jurisprudence and by\\u000a the medical profession
BackgroundWe conducted an Internet-based randomized trial comparing three valence framing presentations of the benefits of antihypertensive medication in preventing cardiovascular disease (CVD) for people with newly diagnosed hypertension to determine which framing presentation resulted in choices most consistent with participants' values.Methods and FindingsIn this second in a series of televised trials in cooperation with the Norwegian Broadcasting Company, adult volunteers
Cheryl L. L. Carling; Doris Tove Kristoffersen; Andrew D. Oxman; Signe Flottorp; Atle Fretheim; Holger J. Schünemann; Elie A. Akl; Jeph Herrin; Thomas D. MacKenzie; Victor M. Montori; Glyn Elwyn
In this study we examine which factors are related to compliance with medication in patients suffering from rheumatoid arthritis (RA). Patients: persons suffering recently developed, active RA, who cooperated in a randomized study on the effect of patient education. We analyzed the relation between adherence to Sulphasalazine therapy and personal factors, environmental influences, demographic factors, disease-related factors, and barriers to
Herman Brus; Martin van de Laar; Erik Taal; Johannes Rasker; Oene Wiegman
Physicians may employ the concept of medical futility to justify a decision not to pursue certain treatments that may be requested\\u000a or demanded by patients or surrogates. Medical futility means that the proposed therapy should not be performed because available\\u000a data show that it will not improve the patient’s medical condition. Medical futility remains ethically controversial for several\\u000a reasons. Some
During the winter in 2008, Iowa experienced an increase in sudden unexplained infant deaths (SUIDs). SUIDs and infectious causes of infant deaths generally average 3 monthly (SD = 1.0) in Iowa. However, in January 2008, 9 infant deaths were reported to the Iowa Department of Public Health and the Iowa Office of the State Medical Examiner. Between January and March of 2008, joint investigation of 22 SUIDs was conducted. The investigations required the involvement of multiple medical examiners from various jurisdictions, testing for pathogens at the University Hygienic Laboratory, epidemiologic support from the Iowa Department of Public Health, and consultation with the Centers for Disease Control and Prevention. The preliminary hypotheses for the increase in the infant mortality included viral respiratory disease and/or possible novel respiratory viral infections being the cause. Collaboration between public health and the medical examiner offices resulted in timely assessment of the cases. While no single causative agent was responsible for the increase seen in the number of infant deaths, respiratory pathogens played a role in the deaths of 15 of 22 children. PMID:20938328
Decision-making is a crucial task for decision makers in healthcare, especially because decisions have to be made quickly, accurately and under uncertainty. Taking into account the importance of providing quality decisions, offering assistance in this complex process has been one of the main challenges of Artificial Intelligence throughout history. Decision Support Systems (DSS) have gained popularity in the medical field for their efficacy to assist decision-making. In this sense, many DSS have been developed, but only few of them consider processing and analysis of information contained in electronic health records, in order to identify individual or population health risk factors. This paper deals with Intelligent Decision Support Systems that are integrated into Electronic Health Records Systems (EHRS) or Public Health Information Systems (PHIS). It provides comprehensive support for a wide range of decisions with the purpose of improving quality of care delivered to patients or public health planning, respectively. PMID:23739355
This paper examines how the decision-making process and its consequences affect medical technology transfer in major Chinese medical schools. Data are from a 1987 survey of 13 key medical universities, directly supervised by the Ministry of Public Health in the People's Republic of China. This paper limits itself to four types of laboratory equipment--electron microscopes, UV/VIS spectrophotometers, high-performance liquid chromatographs, and polygraphs. Decisions on the transfer of medical technology have been more decentralized in China since the economic reform in 1978. The major reason for schools to import these four types of equipment is their dissatisfaction with the quality of domestic products. Chinese medical schools depend heavily on the information provided at medical equipment exhibits and their neighboring schools. Their decisions to acquire the equipment are based more on the quality and service available than on the prices. Chinese medical schools face serious infrastructure problems in acquiring and maintaining these pieces of equipment. A number of suggestions are made for improving the efficiency of medical technology transfer in China. PMID:1778700
Background There is evidence that graduates of different medical schools vary in their preparedness for their first post. In 2003 Goldacre et al. reported that over 40% of UK medical graduates did not feel prepared and found large differences between graduates of different schools. A follow-up survey showed that levels of preparedness had increased yet there was still wide variation. This study aimed to examine whether medical graduates from three diverse UK medical schools were prepared for practice. Methods This was a qualitative study using a constructivist grounded theory approach. Prospective and cross-sectional data were collected from the three medical schools. A sample of 60 medical graduates (20 from each school) was targeted. They were interviewed three times: at the end of medical school (n = 65) and after four (n = 55) and 12 months (n = 46) as a Year 1 Foundation Programme doctor. Triangulated data were collected from clinicians via interviews across the three sites (n = 92). In addition three focus groups were conducted with senior clinicians who assess learning portfolios. The focus was on identifying areas of preparedness for practice and any areas of lack of preparedness. Results Although selected for being diverse, we did not find substantial differences between the schools. The same themes were identified at each site. Junior doctors felt prepared in terms of communication skills, clinical and practical skills and team working. They felt less prepared for areas of practice that are based on experiential learning in clinical practice: ward work, being on call, management of acute clinical situations, prescribing, clinical prioritisation and time management and dealing with paperwork. Conclusions Our data highlighted the importance of students learning on the job, having a role in the team in supervised practice to enable them to learn about the duties and responsibilities of a new doctor in advance of starting work.
Heart and vein diseases are one of the most important health problems. The number of the people who died of heart and vein diseases is more than the number of the people who died of all other health problems and natural disasters. In order to decrease this number, the intervention must be started very earlier and people must be informed
Multiple myeloma (MM) is a malignant disorder characterized by the monoclonal proliferation of B cell derived plasma cells in the bone marrow. The diagnosis depends on the identification of abnormal monoclonal marrow plasma cells, monoclonal protein in the serum or urine, evidence of end-organ damage, and a clinical picture consistent with MM. The distinction between MM stages- monoclonal gammopathy of undetermined significance or indolent myeloma-is critical in guiding therapy. This paper describes how to produce ontology-driven semiological rules base (SRB) and a consultation form to aid in the diagnosis of plasma cells diseases. We have extracted the MM sub-ontology from the NCI Thesaurus. Using Protégé 3.4.2 and owl1, criteria in the literature for the diagnosis and staging of MM have been added to the ontology. All quantitative parameters have been transformed to a qualitative format. A formal description of MM variants and stages has been given. The obtained ontology has been checked by a reasoner and instantiated to obtain a SRB. The form created has been tested and evaluated utilizing 63 clinical medical reports. The likelihood for a disease being the correct diagnosis is determined by computing a ratio. The resulting tool is relevant for MM diagnosis and staging. PMID:22874162
Dietary supplement use is widespread among adults across races/ethnicities, yet reasons for use can vary across these groups. The Supplement Reporting (SURE) study quantified dietary supplement use and reasons for taking supplements in a multiethnic sample of adults who took at least one supplement. This study explored sociodemographic differences, including by race/ethnicity, associated with specific reasons/motivations for taking dietary supplements, including perceived importance of taking supplements relative to prescription medications. The study time period was March 2005 to August 2006. Participants (n=397) were older adults (ages 52 to 88 years) recruited from the Multiethnic Cohort Study in Hawaii and Los Angeles, CA, with equal representation of males and females from six ethnic groups (ie, white, Japanese American, Native Hawaiian, African American, US-born Latino, and foreign-born Latino). Subgroups of participants were compared by ?(2) tests and logistic regression. The most common reasons for taking supplements were to maintain a healthy life, because they were recommended by a health professional, and to prevent a disease/medical problem. A majority (76%) of participants reported that their dietary supplements were as important as prescription medications, with foreign-born Latinos and Japanese Americans being most likely to state this belief. The relative importance of supplements was not associated with excessive use, but 27% of participants exceeded the upper limit for a nutrient. It is crucial for health professionals to better understand why individuals take supplements and the importance that they attach to their use. This information could lead to better monitoring and education efforts to prevent overuse of supplements and possible interactions with medications. PMID:22818730
Albright, Cheryl L; Schembre, Susan M; Steffen, Alana D; Wilkens, Lynne R; Monroe, Kristine R; Yonemori, Kim M; Murphy, Suzanne P
Dietary supplement use is widespread among adults across races/ethnicities, yet reasons for use may vary across these groups. The SUpplement REporting (SURE) study quantified dietary supplement use and reasons for taking supplements in a multiethnic sample of adults who took at least one supplement. This study explored socio-demographic differences, including by race/ethnicity, associated with specific reasons/motivations for taking dietary supplements, including perceived importance of taking supplements relative to prescription medications. The study time period was March 2005 to August 2006. Participants (n=397) were older adults (age = 52–88 y) recruited from the Multiethnic Cohort Study in Hawaii and Los Angeles, with equal representation of males and females from six ethnic groups (white, Japanese-American, Native Hawaiian, African-American, US-born Latino, and foreign-born Latino). Subgroups of participants were compared by chi-square tests and logistic regression. The most common reasons for taking supplements were to maintain a healthy life, recommended by a health professional, and to prevent a disease/medical problem. A majority (76%) of participants reported that their dietary supplements were as important as prescription medications, with foreign-born Latinos and Japanese-Americans being most likely to state this belief. The relative importance of supplements was not associated with excessive use, but 27% of participants exceeded the upper limit for a nutrient. It is crucial for health professionals to better understand why individuals take supplements and the importance that they attach to their use. This information could lead to better monitoring and education efforts in order to prevent overuse of supplements and possible interactions with medications.
Albright, Cheryl L.; Schembre, Susan M.; Steffen, Alana D.; Wilkens, Lynne R.; Monroe, Kristine R.; Yonemori, Kim M.; Murphy, Suzanne P.
The taxonomic status of the medicallyimportant pitviper of the Bothrops atrox-asper complex endemic to Venezuela, which has been classified as Bothrops colombiensis, remains incertae cedis. To help resolving this question, the venom proteome of B. colombiensis was characterized by reverse-phase HPLC fractionation followed by analysis of each chromatographic fraction by SDS-PAGE, N-terminal sequencing, MALDI-TOF mass fingerprinting, and collision-induced dissociation
Juan J. Calvete; Adolfo Borges; Álvaro Segura; Marietta Flores-Díaz; Alberto Alape-Girón; José María Gutiérrez; Nardy Diez; Leonardo De Sousa; Demetrio Kiriakos; Eladio Sánchez; José G. Faks; José Escolano; Libia Sanz
Arguing that management principles and solutions can apply to a public service, this study focuses on service quality and customer relationship to facilitate customer loyalty in the health care industry. Five hundred copies of questionnaires were distributed by convenient sampling, of which 332 questionnaires were usable with a response rate of 66.4%. It finds that service quality is an important
Background Since the completion of three clinical trials indicating that voluntary medical male circumcision (VMMC) is an effective method to reduce men’s chances of acquiring HIV, use of the procedure has been advocated in Kenya. Media messages shape popular understandings of the benefits and limitations of male circumcision. The objectives of this study were to (1) investigate promotion messages in a popular online newspaper to determine how the limitations of male circumcision are represented, and whether condom use is still being promoted; and (2) gain insight into popular understandings of the limitations of this new procedure through newspaper reader comments. Methods A content analysis was conducted on 34 online media articles published by the Daily Nation between January 1, 2008 and December 31, 2010. Information about condom promotion, partial immunity, limitations and complications of the procedure, as well as emergent themes, were analyzed. Results Results demonstrated an irregular and occasionally misleading presentation of these topics and a perceived lack of objective information about the risks and limitations of VMMC. Conclusions There is a need for governmental and non-governmental public health organizations to engage with the media to improve risk messaging.
At beginning of 1991, the increasing necessity of emergency surgical treatment of wounded persons in Croatia led to the formation of mobile surgical teams. However, this system was abandoned due to many problems and echelon health division was formed. One of the war surgical hospitals (second echelon) was the War Surgical Hospital Garesnica. In this study, materials of the Croatian War Veterans Ministry, Ministry of Defense, Garesnica War Surgical Hospital and Garesnica Defense Office archive were used. We analyzed the number and localization of wounds, and describe the organization, work and results of the War Surgical Hospital in Garesnica. During the work of the War Surgical Hospital in Garesnica, 909 surgical examinations were performed, 521 wounded were surgically treated (45% civilians and 55% soldiers), 331 wounded were operated on, 5 lethal outcomes were recorded, 68% of wounds were localized on the extremities, 19% on the thorax and abdomen, and 13% on the head end neck. In this article the organization and work of the War Surgical Hospital in Garesnica is described, which had a major role in providing emergency medical care to people wounded in west Slavonia. PMID:19580229
A team of physicians, pharmacists, and informatics professionals developed a CDSS added to a commercial electronic medical record system to provide prescribers with patient-specific maximum dosing recommendations based on renal function. We tracked the time spent by team members and used US national averages of relevant hourly wages to estimate costs. The team required 924.5 hours and $48,668.57 in estimated costs to develop 94 alerts for 62 drugs. The most time intensive phase of the project was preparing the contents of the CDSS (482.25 hours, $27,455.61). Physicians were the team members with the highest time commitment (414.25 hours, $25,902.04). Estimates under alternative scenarios found lower total cost estimates with the existence of a valid renal dosing database ($34,200.71) or an existing decision support add-on for renal dosing ($23,694.51). Development of a CDSS for a commercial computerized prescriber order entry system requires extensive commitment of personnel, particularly among clinical staff.
Field, Terry S.; Rochon, Paula; Lee, Monica; Gavendo, Linda; Subramanian, Sujha; Hoover, Sonia; Baril, Joann; Gurwitz, Jerry
In this chapter a review of research published since 2000 on the biology of the snail intermediate hosts of trematode parasites of medicalimportance in Southeast Asia, and related taxa is presented. Recent taxonomic revisions of the first intermediate hosts of Paragonimus in the region are considered and an account of changes in current perspectives regarding the evolution of intermediate-host:parasite associations for both Paragonimus and Schistosoma is given. The latest phylogeographical hypotheses for Schistosoma, Paragonimus, Fasciola and Fasciolopsis are also reviewed and compared. Work performed in the region on the snail intermediate hosts of other less studied parasites, such as Opisthorchis/Clonorchis and haplorchids, is also described. PMID:20627149
In response to a climate of constant change and increasing demand for services, general practice in the UK has undergone significant modification over the last 10 years. It has become a multi-disciplinary organisation encouraged by funding bodies to plan for service delivery using a more structured team based approach. In Tayside in 1996, practices were charged with producing formal Practice Development Plans (PDPs) which would focus on priority areas aligned with the Health Boards own strategic plan--those were teamwork, information management and technology, and clinical service delivery. The University of Dundee's Department of General Practice successfully applied for funding to develop ways of facilitating practices so that they could a) identify their own development priorities, and b) plan and implement action and learning to see these priorities through. Using action research methodology, the project attempted to create a climate for change, provide support and training to see the changes implemented, and ensure commitment to the changes from all members of the practice team. The Facilitator adopted a flexible style varying her role between expert, guide and support. Analysis of progress made by different practices, coupled with the Facilitator's in depth knowledge of them, suggested the importance of certain key aspects of practice organisation and culture. A practice characterisation model identified practices which were stable, currently coping, proactive and ready to face the challenge of change as best placed to engage in a full scale development programme. Other profiles suggested a range of alternative interventions as more likely to be acceptable and productive. PMID:11499046
The roles of academic librarians and administrators include the use of statistical analysis and general analytical abilities in their decision-making processes, as well as in their roles as researchers, in developing research collections, and in providing instruction and reference assistance for students and other researchers. The research presented in this article addresses the original research published in frequently cited library
BackgroundPharmacotherapy is an integral part of any medical care process and plays an important role in the medical history of most patients. Information on medication is crucial for several tasks such as pharmacovigilance, medicaldecision or biomedical research.ObjectivesWithin a narrative text, medication-related information can be buried within other non-relevant data. Specific methods, such as those provided by text mining, must
A newly developed commercial serological test (Iatron Laboratories, Inc., Tokyo, Japan) for the rapid identification of medicallyimportant species of Candida was evaluated against the API 20C (Analytab Products, Plainview, N.Y.) and the standard Wickerham assimilation and fermentation procedures. Our results indicated that the Iatron and the API 20C methods are 95% accurate since both permitted identification of 78 of 82 Candida isolates, representing eight medicallyimportant species. None of the tests on nine Cryptococcus, six Trichosporon, three Geotrichum, three Saccharomyces, and one Rhodotorula species yielded false-positive reactions. False-positive serological tests occurred with a species of Pichia and Candida rugosa. The API 20C procedure correctly identified C. rugosa but not the Pichia sp. The Iatron method permitted reliable identification of the Candida species in 10 min to 5 h, whereas the API 20C procedure required 48 to 72 h. Neither method could properly identify sucrose-negative Candida tropicalis or Candida lusitaniae isolates. In addition, Candida albicans isolates could be serotyped by the Iatron method.
We have developed PCR and Multiplex PCR assays for the detection of medicallyimportant Candida spp. using different species and genus-specific PCR primers selected within the MP65 gene, a recently cloned gene encoding a mannoprotein adhesin. The genus-specific PCR primers were able to amplify Candida species DNA (100% positivity) whereas DNA from all other isolates tested, belonging to other fungal genera, was not amplified. The species-specific PCR primers allowed differentiation of each of five Candida species by the amplicon length produced. No amplicons were detected using species- or genus-specific primers in several bacterial or human DNA templates. The methods described in this study are reproducible, simple and specific. The total time required for each PCR method was less than 4 h from the extraction to the visualized amplicons after PCR. In conclusion, we developed PCR methods to differentiate the five most medicallyimportant Candida species using primers directed to the MP65 gene. PMID:19393314
Arancia, S; Sandini, S; Cassone, A; De Bernardis, F
Supply management professionals make things happen. Through your person, your position, and your style you influence other people. Success in your department or organization reflects on your ability to make sound decisions. In fact, in professional life it is often more important to be decisive than it is to be right. Decisiveness inspires support in addition to intimidating the opposition.
Background:In the Netherlands physicians are allowed to grant requests for euthanasia or physician-assisted suicide (EAS) if they meet several requirements of due care. According to jurisprudence, a physician is not allowed to end the life of a patient whose request for EAS is based on being ‘tired of living’, because such a request falls outside the medical domain. Our previous
Mette L. Rurup; Bregje D. Onwuteaka-Philipsen; Marijke C. Jansen-van der Weide; Gerrit van der Wal
BACKGROUND:: In the Netherlands physicians are allowed to grant requests for euthanasia or physician-assisted suicide (EAS) if they meet several requirements of due care. According to jurisprudence, a physician is not allowed to end the life of a patient whose request for EAS is based on being 'tired of living', because such a request falls outside the medical domain. Our
M. L. Rurup; B. D. Philipsen; Weide van der M. C; Wal van der G
The present study aims to explore the influence of person autonomy and voluntariness on the level and orientation of motivation and decision making of crew members who live and work in extreme isolated conditions such as during long-term space flights. Motivation has been related to positive behavioural (e.g., goal-orientation), cognitive (e.g., attention), and psychological (e.g., well-being) outcomes and is likely to be relevant for safe and favourable extraterrestrial life- and working-conditions. The study has been carried out within the scope of the Mars500 study which includes a Mars mission simulation of 105 (pilot study) and 520 (main study) days and involves a multi-national crew of 6 men who lived and worked in hermetically sealed modules in the IBMP facilities in Moscow. Data have been collected by the use of questionnaires that evaluate the Mars experiment in terms of, e.g. information received (e.g., "My experiences here are in line with what I was told during the selection and instruction procedure"), perceived social pressure (e.g., "I don't feel free to make my own decisions"), and personal challenge (e.g., "I think that joining the first Mars mission would be a major challenge for me"). It is hypothesised that stronger (1) perceived information consistency, (2) personal expectation consistency, (3) perceived voluntariness, and (4) experienced freedom of choice will be indicative of higher motivation levels. The results will be interpreted in the light of communication, decision making processes, and mission safety. Also, moral expectations and ethical considerations regarding future participation in long duration Human missions such as Mars will be discussed. We will make use of descriptive, longitudinal pattern analyses and correlations.
No evidence-based information exists to guide clinicians for giving presumptive treatment to returning travelers when malaria is strongly suspected on clinical grounds but laboratory confirmation is not immediately available or is negative. A prospective study was conducted in travelers or migrants who sought care for fever to identify clinical and laboratory predictors of Plasmodium parasitemia. A total of 336 questionnaires were collected (97 malaria case patients and 239 controls). Multivariate regression analysis showed inadequate prophylaxis, sweating, no abdominal pain, temperature > or = 38 degrees C, poor general health, enlarged spleen, leucocytes < or = 10 x 10(3)/L, platelets < 150 x 10(3)/L, hemoglobin < 12 g/dL, and eosinophils < or = 5% to be associated with parasitemia. Enlarged spleen had the highest positive likelihood ratio for a diagnosis of malaria (13.6), followed by thrombopenia (11.0). Posttest probabilities for malaria were 85% with enlarged spleen and 82% with thrombopenia. A rapid assessment can thus help to decide whether a presumptive treatment should be given or not, especially when the results of the parasitological examination are not immediately available or are uncertain. PMID:12201580
Hundreds of contaminated facilities and sites must be cleaned up. ''Cleanup'' includes decommissioning, environmental restoration, and waste management. Cleanup can be complex, expensive, risky, and time-consuming. Decisions are often controversial, can stall or be blocked, and are sometimes re-done--some before implementation, some decades later. Making and keeping decisions with long time horizons involves special difficulties and requires new approaches. Our project goal is to make cleanup decisions easier to make, implement, keep, and sustain. By sustainability, we mean decisions that work better over the entire time-period-from when a decision is made, through implementation, to its end point. That is, alternatives that can be kept ''as is'' or adapted as circumstances change. Increased attention to sustainability and adaptability may decrease resistance to making and implementing decisions. Our KONVERGENCE framework addresses these challenges. The framework is based on a mental model that states: where Knowledge, Values, and Resources converge (the K, V, R in KONVERGENCE), you will find a sustainable decision. We define these areas or universes as follows: (1) Knowledge: what is known about the problem and possible solutions? (2) Values: what is important to those affected by the decision? (3) Resources: what is available to implement possible solutions or improve knowledge? This mental model helps analyze and visualize what is happening as decisions are made and kept. Why is there disagreement? Is there movement toward konvergence? Is a past decision drifting out of konvergence? The framework includes strategic improvements, i.e., expand the spectrum of alternatives to include adaptable alternatives and decision networks. It includes tactical process improvements derived from experience, values, and relevant literature. This paper includes diagnosis and medication (suggested path forward) for intractable cases.
Piet, S. J.; Gibson, P. L.; Joe, J. C.; Kerr, T. A.; Nitschke, R. L.; Dakins, M. E.
The United States faces many existing and emerging mosquito-borne disease threats, such as West Nile virus and Rift Valley fever. An important component of strategic prevention and control plans for these and other mosquito-borne diseases is forecasting the distribution, timing, and abundance of mosquito vector populations. Populations of many medicallyimportant mosquito species are closely tied to climate, and historical climate-population associations may be used to predict future population dynamics. Using 2003-2005 U.S. Army Center for Health Promotion and Preventive Medicine mosquito surveillance data, we looked at populations of several known mosquito vectors of West Nile virus, as well as possible mosquito vectors of Rift Valley fever virus, at continental U.S. military installations. We compared population changes with concurrent patterns for a satellite-derived index of climate (normalized difference vegetation index) and observed instances of population changes appearing to be direct responses to climate. These preliminary findings are important first steps in developing an automated, climate-driven, early warning system to flag regions of the United States at elevated risk of mosquito-borne disease transmission. PMID:18700603
|Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…
Administered Beisecker Locus of Authority in Decision Making: Breast Cancer survey to 67 oncologists, 94 oncology nurses, and 288 patients from women's clinic. All groups believed that physicians should have dominant role in decision making. Nurses felt that patients should have more input than patients or physicians felt they should. Physicians…
Diagnosis of invasive pulmonary aspergillosis (IPA) remains a major challenge to clinical microbiology laboratories. We developed rapid and sensitive quantitative PCR (qPCR) assays for genus- and species-specific identification of Aspergillus infections by use of TaqMan technology. In order to validate these assays and understand their potential diagnostic utility, we then performed a blinded study of bronchoalveolar lavage (BAL) fluid specimens from well-characterized models of IPA with the four medicallyimportant species. A set of real-time qPCR primers and probes was developed by utilizing unique ITS1 regions for genus- and species-specific detection of the four most common medicallyimportant Aspergillus species (Aspergillus fumigatus, A. flavus, A. niger, and A. terreus). Pan-Aspergillus and species-specific qPCRs with BAL fluid were more sensitive than culture for detection of IPA caused by A. fumigatus in untreated (P < 0.0007) and treated (P ? 0.008) animals, respectively. For infections caused by A. terreus and A. niger, culture and PCR amplification from BAL fluid yielded similar sensitivities for untreated and treated animals. Pan-Aspergillus PCR was more sensitive than culture for detection of A. flavus in treated animals (P = 0.002). BAL fluid pan-Aspergillus and species-specific PCRs were comparable in sensitivity to BAL fluid galactomannan (GM) assay. The copy numbers from the qPCR assays correlated with quantitative cultures to determine the pulmonary residual fungal burdens in lung tissue. Pan-Aspergillus and species-specific qPCR assays may improve the rapid and accurate identification of IPA in immunocompromised patients.
Walsh, Thomas J.; Wissel, Mark C.; Grantham, Kevin J.; Petraitiene, Ruta; Petraitis, Vidmantas; Kasai, Miki; Francesconi, Andrea; Cotton, Margaret P.; Hughes, Johanna E.; Greene, Lora; Bacher, John D.; Manna, Pradip; Salomoni, Martin; Kleiboeker, Steven B.; Reddy, Sushruth K.
The research into agent-based intelligent decision support systems is important to the medical industry because these systems can be used to improve the quality of healthcare in many ways. The areas these systems can be used in are diverse from the storage of medical records to the examination and evaluation of real-time data gathered from monitors. These systems are helpful
Hundreds of contaminated facilities and sites must be cleaned up. “Cleanup” includes decommissioning, environmental restoration, and waste management. Cleanup can be complex, expensive, risky, and time-consuming. Decisions are often controversial, can stall or be blocked, and are sometimes re-done - some before implementation, some decades later. Making and keeping decisions with long time horizons involves special difficulties and requires new approaches, including: • New ways (mental model) to analyze and visualize the problem, • Awareness of the option to shift strategy or reframe from a single decision to an adaptable network of decisions, and • Improved tactical processes that account for several challenges. These include the following: • Stakeholder values are a more fundamental basis for decision making and keeping than “meeting regulations.” • Late-entry players and future generations will question decisions. • People may resist making “irreversible” decisions. • People need “compelling reasons” to take action in the face of uncertainties. Our project goal is to make cleanup decisions easier to make, implement, keep, and sustain. By sustainability, we mean decisions that work better over the entire time-period—from when a decision is made, through implementation, to its end point. That is, alternatives that can be kept “as is” or adapted as circumstances change. Increased attention to sustainability and adaptability may decrease resistance to making and implementing decisions. Our KONVERGENCE framework addresses these challenges. The framework is based on a mental model that states: where Knowledge, Values, and Resources converge (the K, V, R in KONVERGENCE), you will find a sustainable decision. We define these areas or universes as follows: • Knowledge: what is known about the problem and possible solutions? • Values: what is important to those affected by the decision? • Resources: what is available to implement possible solutions or improve knowledge? This mental model helps analyze and visualize what is happening as decisions are made and kept. Why is there disagreement? Is there movement toward konvergence? Is a past decision drifting out of konvergence? The framework includes strategic improvements, i.e., expand the spectrum of alternatives to include adaptable alternatives and decision networks. It includes tactical process improvements derived from experience, values, and relevant literature. This paper includes diagnosis and medication (suggested path forward) for intractable cases.
Piet, Steven James; Gibson, Patrick Lavern; Joe, Jeffrey Clark; Kerr, Thomas A; Nitschke, Robert Leon; Dakins, Maxine Ellen
While legal rights to make medical treatment decisions at the end of one's life have been recognized by the courts, particular religious traditions put axiological and metaphysical meat on the bare bones of legal rights. Mere legal rights do not capture the full reality, meaning and importance of death. End-of-life decisions reflect not only the meaning we find in dying, but also the meaning we have found in living. The Christian religions bring particular understandings of the vision of life as a gift from God, human responsibility for stewardship of that life, the wholeness of the person, and the importance of the dying process in preparing spiritually for life beyond earthly life, to bear on end-of-life decisions. PMID:11655316
The clinician's decisions are subject to numerous distorting influences. Computer decision aids can help avoid these distortions by placing the clinician's limited personal experience into broader perspective through comparison with a larger repository of clinically relevant information; by making explicit the assumptions implied by his or her decisions; and by alerting the clinician whenever the decisions made do not appear consistent with these assumptions, with the available information or with the conventional rules of logic. Practical standards of performance with respect to the development, validation and clinical application of these decision aids are still in evolution, however, and a variety of ethical and legal issues have yet to be addressed. Despite the promise of computer decision aids, it remains to be seen whether their diffusion into medical practice will improve the quality and cost of health care. PMID:3584725
Suicide is a very common problem in psychiatric practice today. Therefore, almost all staff of psychiatric hospitals have encountered the suicide of one or more of their patients. Our hospital, Osaka Psychiatric Medical Center, is a public psychiatric hospital in Japan. We provide treatment and support for patients from the acute to chronic phases of psychiatric disorders, and patients range from children to the elderly. Because we accept many patients with severe mental illness from other hospitals, many of our staff are routinely confronted with patients' violence or suicidal attempts. If a patient commits suicide, the relevant staff immediately have a conference to implement measures for preventing a recurrence. At the same time, information about the incident is conveyed to the medical safety management office and made known to all staff in our hospital. This office was established in 2007. Currently, all information about incidents and accidents in our hospital (e.g., suicide, problems between patients, problems with hospital facilities) is aggregated in the office and distributed to all staff members through the hospital intranet. This system makes it possible for staff to consider countermeasures against similar incidents and accidents, even if not involved in the incident. Additionally, we make an effort to develop cooperative relationships with organizations including the police, public health centers, and the fire department. The social welfare council in Hirakata City, where our hospital is located, provides some services to prevent suicide (e.g., telephone counseling, meetings with bereaved family members). Our hospital cooperates with these services by providing lecturers. The partnerships with these organizations help regarding the mental crises of patients in our hospital and fulfill a role to prevent suicide. Multi-disciplinary cooperation and partnerships with community organizations are not special approaches to suicide prevention, but ordinary approaches in everyday clinical practice. The most important factor is the relationship between staff and organizations relevant to preventing suicide. PMID:23346818
...activity relating to drug abuse, alcoholism or alcohol abuse, infection with the human immunodeficiency virus, or sickle cell anemia to a surrogate of the patient who is the subject of such record if: (a) The patient lacks decision-making...
Item response theory differential test functioning (DTF) methods are often used to address issues in personnel selection, but the results are frequently difficult to interpret because statistically significant findings may have little practical importance. In this article, the authors proposed 2 effect size measures for DTF. One related DTF to mean raw score differences across groups; the other related DTF
Stephen Stark; Oleksandr S. Chernyshenko; Fritz Drasgow
OBJECTIVE To identify the desired features of end-of-life medicaldecision making from the perspective of elderly individuals. DESIGN Qualitative study using in-depth interviews and analysis from a phenomenologic perspective. SETTING A senior center and a multilevel retirement community in Los Angeles. PARTICIPANTS Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making. MAIN RESULTS Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a “full life.” Decision-making authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient's interests), and shifted from physician to family as the patient's prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions. CONCLUSIONS These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients' end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients' and families' goals for care.
Rosenfeld, Kenneth E; Wenger, Neil S; Kagawa-Singer, Marjorie
In Switzerland there is a strong movement at a national policy level towards strengthening patient rights and patient involvement in health care decisions. Yet, there is no national programme promoting shared decision making. First decision support tools (prenatal diagnosis and screening) for the counselling process have been developed and implemented. Although Swiss doctors acknowledge that shared decision making is important, hierarchical structures and asymmetric physician-patient relationships are still prevailing. The last years have seen some promising activities regarding the training of medical students and the development of patient support programmes. Swiss direct democracy and the habit of consensual decision making and citizen involvement in general may provide a fertile ground for SDM development in the primary care setting. PMID:21620324
The pace of medical technological development shows no sign of abating. An- alyzing the effect of major federal health agencies on the availability of such technology is critical. This paper describes functions of three government health agencies: the Centers for Medicare and Medicaid Services (CMS), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH). Certain medical
Larry Kessler; Scott D. Ramsey; Sean Tunis; Sean D. Sullivan
Mobile devices are becoming more and more important for services offered either directly to individuals, or indirectly as part of a therapeutic or rehabilitation procedure. Representing the work of the EFMI WG "Personal Portable Devices", this paper offers an introduction to some of the most important technical and privacy-related challenges that arise when introducing mobile sensor or actuator devices (and networks) into health care, wellness, and fitness processes in order to exploit their capability to collect, record and process personal health data. Data processing can be viewed in three classes of application, namely processes for recommendations, decision support and decision making in personalized health and wellbeing service provision. This paper therefore briefly addresses aspects such as the Medical Device Directive for certifying devices in that respect. But regardless whether being MDD-compliant or not, each class of devices may have its own benefits and weaknesses in terms of enabling health-related personalized decisions. PMID:23739352
Medical liability is one of the most important parts of law that regulates health services. Although there are different types of liability in the field of medicine (criminal responsibility, disciplinary proceedings) civil law liability holds central position. Civil law liability in medicine (medical liability) is probably more important than criminal responsibility and disciplinary proceedings because of the number of cases in comparison to the criminal responsibility and impact of the consequences in comparison to the disciplinary proceedings. Medical liability is governed by a (general) tort law. Therefore medical liability exists only if conditions for civil law liability are met. When considering medical liability it is necessary to emphasize that tortfeasor will not be liable only because victim sustained the damage, but if all conditions for liability are met. Medical liability will arise if actions of physician are not conducted lege artis or in a breach of the duty of care. In some cases of medical liability legal sources are directly applicable (informed consent). General tort law is also applicable on decisions in the respect of the damages. PMID:19146185
Shared decision-making is an essential element of patient-centered care in mental health. Since mental health services involve healthcare providers from different professions, a multiple perspective to shared decision-making may be valuable. The objective of this study was to explore the perceptions of different healthcare professionals on shared decision-making and current interprofessional collaboration in mental healthcare. Semi-structured interviews were conducted with 31 healthcare providers from a range of professions, which included medical practitioners (psychiatrists, general practitioners), pharmacists, nurses, occupational therapists, psychologists and social workers. Findings indicated that healthcare providers supported the notion of shared decision-making in mental health, but felt that it should be condition dependent. Medical practitioners advocated a more active participation from consumers in treatment decision-making; whereas other providers (e.g. pharmacists, occupational therapists) focused more toward acknowledging consumers' needs in decisions, perceiving themselves to be in an advisory role in supporting consumers' decision-making. Although healthcare providers acknowledged the importance of interprofessional collaboration, only a minority discussed it within the context of shared decision-making. In conclusion, healthcare providers appeared to have differing perceptions on the level of consumer involvement in shared decision-making. Interprofessional roles to facilitate shared decision-making in mental health need to be acknowledged, understood and strengthened, before an interprofessional approach to shared decision-making in mental health can be effectively implemented. PMID:23421345
At Landstuhl Army Regional Medical Center (LARMC), the increase in the number of inpatients due to Operations Desert Shield and Desert Storm had made leaders acutely aware of efficiency issues throughout the facility. One key area targeted for improvement...
This article reports on a study that examines the influence of task-related factors on nurses' pain assessments and decisions regarding interventions. In an experimental design pediatric nurses (n = 202), were exposed to different cases, each case being a combination of a vignette and a videotape. For every case subjects were asked to assess the child's pain and to state
Jan P. H. Hamers; Huda Huijer Abu-Saad; Marcel A. van den Hout; Ruud J. G. Halfens; Arnold D. M. Kester
BACKGROUND: Many preventable diseases such as ischemic heart diseases and breast cancer prevail at a large scale in the general population. Computerized decision support systems are one of the solutions for improving the quality of prevention strategies. METHODS: The system called EsPeR (Personalised Estimate of Risks) combines calculation of several risks with computerisation of guidelines (cardiovascular prevention, screening for breast
The Jinyang Lake is dammed up Nam River, and surrounded by Jinju city and four counties; Jinyang, Sanchong, Hadong, and Sachon in Kyongsang-Nam-Do, Korea. The area around this man-made lake have been known as an endemic focus of clonorchiasis in Korea. The present study was first aimed to know the distribution of freshwater mollusks including medicallyimportant snails, and larval trematodes shed from Parafossarulus manchouricus and Semisulcospira libertina. In addtion to above studies, water analyses in each snail habitat were carried out in order to figure out a part of their environmental factors. This malaco-ecological survey was done at the six areas around upper, middle and lower parts of the lake for 4 months, August-November, 1983. Total nine species of freshwater mollusks were collected throughout the study: 4 species of gastropods; Semisulcospira libertina, Cipangopaludina chinensis, Parafossarulus manchouricus and Radix auricularia, and 5 species of bivalves; Unio douglasiae, Anodonta woodiana, Lamprotula gottschei, Corbicula fluminea and Limnoperma lucustris. Out of nine species of freshwater mollusks, three species of gastropods; S. libertina, P. manchouricus and R. auricularia were medicallyimportant in terms of the transmission of digenetic trematodes to humans. P. manchouricus and R. auricularia were mainly collected from the shallow ponds and the irrigation channels with the muddy basin, but S. libertina and the bivalves were only collected from the stream of Nam river where the gravels and rocks were dominant. The levels of dissolved oxygen(D.O.) and biochemical oxygen demand (B.O.D.(5)) of the water specimens sampled from the study areas ranged from 6.0 to 9.6 ppm and from 0.4 to 1.6 ppm respectively. As a result, it is considered that water system around the Jinyang Lake might be relatively clean without any heavy pollution of aquatic microorganisms and organic materials during the period of this study. On the other hand, eight metalic constituents from the water samples were also assayed, and all metalic ions detected were remarkably low below the legal criteria. However, calcium ion in the water samples from the habitats of P. manchouricus was considerably higher than others. Infection rates of digenetic trematodes in the snails were 6.9 % in P. manchouricus and 4.8 poercent in S. libertina, respectively. P. manchouricus snails harboring with the cercariae of Clonorchis sinensis were only 0.14 % among the snails examined and other trematode cercariae except cercaria of C. sinensis were; furcocercus cercariae, cercaria of Loxogenes liberum type I and II. S. libertina snails parasitized with the cercariae of Metagonimus yokogawai were 1.5 % out of the snails examined and no cercaria of Paragonimus westermani was found in S. libertina snails in the present study. Digenetic trematode cercariae other then M. yokogawai in S. libertina snails were: Cercaria yoshidae (B type), Cercaria cristata, Cercaria innominatum, Cercaria of Centrocestus formosanus and Cercaria nipponensis. PMID:12902649
Despite the increasing use of 16S rRNA gene sequencing, interpretation of 16S rRNA gene sequence results is one of the most difficult problems faced by clinical microbiologists and technicians. To overcome the problems we encountered in the existing databases during 16S rRNA gene sequence interpretation, we built a comprehensive database, 16SpathDB (http://184.108.40.206/16SpathDB) based on the 16S rRNA gene sequences of all medicallyimportant bacteria listed in the Manual of Clinical Microbiology and evaluated its use for automated identification of these bacteria. Among 91 nonduplicated bacterial isolates collected in our clinical microbiology laboratory, 71 (78%) were reported by 16SpathDB as a single bacterial species having >98.0% nucleotide identity with the query sequence, 19 (20.9%) were reported as more than one bacterial species having >98.0% nucleotide identity with the query sequence, and 1 (1.1%) was reported as no match. For the 71 bacterial isolates reported as a single bacterial species, all results were identical to their true identities as determined by a polyphasic approach. For the 19 bacterial isolates reported as more than one bacterial species, all results contained their true identities as determined by a polyphasic approach and all of them had their true identities as the “best match in 16SpathDB.” For the isolate (Gordonibacter pamelaeae) reported as no match, the bacterium has never been reported to be associated with human disease and was not included in the Manual of Clinical Microbiology. 16SpathDB is an automated, user-friendly, efficient, accurate, and regularly updated database for 16S rRNA gene sequence interpretation in clinical microbiology laboratories.
Woo, Patrick C. Y.; Teng, Jade L. L.; Yeung, Juilian M. Y.; Tse, Herman; Lau, Susanna K. P.; Yuen, Kwok-Yung
|This collection of essays focuses on the importance of accurate and timely information for effective decision making. First, Ivan Lach considers the proliferation of statewide planning and policy formation and discusses problems with and ways to improve statewide research. Next, Cheryl Opacinch focuses on decision making for federal postsecondary…
|Decision making is the most common kind of problem solving. It is also an important component skill in other more ill-structured and complex kinds of problem solving, including policy problems and design problems. There are different kinds of decisions, including choices, acceptances, evaluations, and constructions. After describing the…
Background Many preventable diseases such as ischemic heart diseases and breast cancer prevail at a large scale in the general population. Computerized decision support systems are one of the solutions for improving the quality of prevention strategies. Methods The system called EsPeR (Personalised Estimate of Risks) combines calculation of several risks with computerisation of guidelines (cardiovascular prevention, screening for breast cancer, colorectal cancer, uterine cervix cancer, and prostate cancer, diagnosis of depression and suicide risk). We present a qualitative evaluation of its ergonomics, as well as it's understanding and acceptance by a group of general practitioners. We organised four focus groups each including 6–11 general practitioners. Physicians worked on several structured clinical scenari os with the help of EsPeR, and three senior investigators leaded structured discussion sessions. Results The initial sessions identified several ergonomic flaws of the system that were easily corrected. Both clinical scenarios and discussion sessions identified several problems related to the insufficient comprehension (expression of risks, definition of familial history of disease), and difficulty for the physicians to accept some of the recommendations. Conclusion Educational, socio-professional and organisational components (i.e. time constraints for training and use of the EsPeR system during consultation) as well as acceptance of evidence-based decision-making should be taken into account before launching computerised decision support systems, or their application in randomised trials.
|The National Medical Library of Cuba is currently developing an information literacy program to train users in the use of biomedical databases. This paper describes the experience with the course "Cochrane Library: Evidence-Based Medicine," which aims to teach users how to make the best use of this database, as well as the evidence-based medicine…
Santana Arroyo, Sonia; del Carmen Gonzalez Rivero, Maria
The taxonomic status of the medicallyimportant pitviper of the Bothrops atrox-asper complex endemic to Venezuela, which has been classified as Bothrops colombiensis, remains incertae cedis. To help resolving this question, the venom proteome of B. colombiensis was characterized by reverse-phase HPLC fractionation followed by analysis of each chromatographic fraction by SDS-PAGE, N-terminal sequencing, MALDI-TOF mass fingerprinting, and collision-induced dissociation tandem mass spectrometry of tryptic peptides. The venom contained proteins belonging to 8 types of families. PI Zn(2+)-metalloproteinases and K49 PLA(2) molecules comprise over 65% of the venom proteins. Other venom protein families comprised PIII Zn(2+)-metalloproteinases (11.3%), D49 PLA(2)s (10.2%), l-amino acid oxidase (5.7%), the medium-sized disintegrin colombistatin (5.6%), serine proteinases (1%), bradykinin-potentiating peptides (0.8%), a DC-fragment (0.5%), and a CRISP protein (0.1%). A comparison of the venom proteomes of B. colombiensis and B. atrox did not support the suggested synonymy between these two species. The closest homologues to B. colombiensis venom proteins appeared to be toxins from B. asper. A rough estimation of the similarity between the venoms of B. colombiensis and B. asper indicated that these species share approximately 65-70% of their venom proteomes. The close kinship of B. colombiensis and B. asper points at the ancestor of B. colombiensis as the founding Central American B. asper ancestor. This finding may be relevant for reconstructing the natural history and cladogenesis of Bothrops. Further, the virtually indistinguishable immunological crossreactivity of a Venezuelan ABC antiserum (raised against a mixture of B. colombiensis and Crotalus durissus cumanensis venoms) and the Costa Rican ICP polyvalent antivenom (generated against a mixture of B. asper, Crotalus simus, and Lachesis stenophrys venoms) towards the venoms of B. colombiensis and B. asper, supports this view and suggests the possibility of indistinctly using these antivenoms for the management of snakebites by any of these Bothrops species. However, our analyses also evidenced the limited recognition capability or avidity of these antivenoms towards a number of B. colombiensis and B. asper venom components, most notably medium-size disintegrins, bradykinin-potentiating peptides, PLA(2) proteins, and PI Zn(2+)-metalloproteinases. PMID:19457355
Calvete, Juan J; Borges, Adolfo; Segura, Alvaro; Flores-Díaz, Marietta; Alape-Girón, Alberto; Gutiérrez, José María; Diez, Nardy; De Sousa, Leonardo; Kiriakos, Demetrio; Sánchez, Eladio; Faks, José G; Escolano, José; Sanz, Libia
Decision making is always been an important in social setting. For understanding the process of decision making it is important to understand as to how people make decisions and the factors influence the decisions. Studies (Srinivasan and Sharan 2005, Pescosolido, 1992) show that decisions are not made in isolation but they are the products of influence and confluence of social
Discusses four main types of medical imaging (x-ray, radionuclide, ultrasound, and magnetic resonance) and considers their relative merits. Describes important recent and possible future developments in image processing. (Author/MKR)
|Discusses four main types of medical imaging (x-ray, radionuclide, ultrasound, and magnetic resonance) and considers their relative merits. Describes important recent and possible future developments in image processing. (Author/MKR)|
If medical confidentiality is not observed patients may well be reluctant to disclose information to their doctors or even to seek medical advice. Therefore, argues the author, it is of the utmost importance that doctors strive to protect medical confidentiality, particularly now when it is under threat not only in this country but also overseas. The profession must cease to regard ethical issues to do with confidentiality, and indeed to do with all areas of medical practice, as abstract phenomena requiring no justification. If it does not then it will come under increasing and justified criticism from the community it serves.
In this article the practice of end of life decisions is applied to pregnant women. This is not an easy task as shown by the extensive case law and literature on the subject. The main conclusion of the article is that the pregnant woman's wishes should always be respected whatever the consequences for the foetus may be. Another position would unjustly sacrifice the woman's fundamental rights to bodily integrity and self-determination for the benefit of a non-person. The result is repeated in the situation where the woman is found to be incompetent or brain dead. PMID:21133244
Although progress has been made in the treatment of alcohol use disorders, more effective treatments are needed. In the last 15 years, several medications have been approved for use in alcohol dependence but have only limited effectiveness and clinical acceptance. While academics have developed some ‘standards’ for the performance of clinical trials for alcohol dependence, they vary considerably, in the
Raymond F Anton; Raye Z Litten; Daniel E Falk; Joseph M Palumbo; Raymond T Bartus; Rebecca L Robinson; Henry R Kranzler; Thomas R Kosten; Roger E Meyer; Charles P O'Brien; Karl Mann; Didier Meulien
In medicaldecision making (classification, diagnosing, etc.) there are many situations where decision must be made effectively and reliably. Conceptual simple decision making models with the possibility of automatic learning are the most appropriate for performing such tasks. Decision trees are a reliable and effective decision making technique that provide high classification accuracy with a simple representation of gathered knowledge
Vili Podgorelec; Peter Kokol; Bruno Stiglic; Ivan Rozman
Decision making for patients with spontaneous intracerebral hemorrhage (ICH) poses several challenges. Outcomes in this patient population are generally poor, prognostication is often uncertain, and treatment strategies offer limited benefits. Studies demonstrate variability in the type and intensity of treatment offered, which is attributed to clinical uncertainty and habits of training. Research has focused on new techniques and more stringent evidence-based selection criteria to improve outcomes and produce consensus around treatment strategies for patients with ICH. Such focus, however, offers little description of how ICH treatment decisions are made and how such decisions reflect patient preferences regarding medical care. A growing body of literature suggests that the process of decision making in ICH is laden with bias, value assumptions, and subjective impressions. Factors such as geography, cognitive biases, patient perceptions, and physician characteristics can all shape decision making and the selection of treatment. Such factors often serve as a barrier to providing patient-centered medical care. In this article, the authors review how surgical decision making for patients with ICH is shaped by these decisional factors and suggest future research pathways to study decision making in ICH. Such research efforts are important for establishing quality guidelines and pay-for-performance measures that reflect the preferences of individual patients and the contextual nature of medicaldecision making. PMID:23634913
Kelly, Michael L; Sulmasy, Daniel P; Weil, Robert J
Shared decision making involving patients and physicians has gained adherents in Israel and other countries and has many virtues. This commentary argues that medicaldecision making should ideally be shaped by the particular needs and preferences of the patient, which may be to share in decision making, or at times call for a physician to assume full responsibility for decisions or, at the other extreme, to support and guide a patient who wishes to decide autonomously on what to do. This is a commentary on http://www.ijhpr.org/content/1/1/5/