Complex Problem Solving in Radiologic Technology: Understanding the Roles of Experience, Reflective Judgment, and Workplace Culture

ERIC Educational Resources Information Center

Yates, Jennifer L.

2011-01-01

The purpose of this research study was to explore the process of learning and development of problem solving skills in radiologic technologists. The researcher sought to understand the nature of difficult problems encountered in clinical practice, to identify specific learning practices leading to the development of professional expertise, and to…

Medical Problem-Solving: A Critique of the Literature.

ERIC Educational Resources Information Center

McGuire, Christine H.

1985-01-01

Prescriptive, decision-analysis of medical problem-solving has been based on decision theory that involves calculation and manipulation of complex probability and utility values to arrive at optimal decisions that will maximize patient benefits. The studies offer a methodology for improving clinical judgment. (Author/MLW)

An Assessment of Six School-Based Clinics: Services, Impact and Potential.

ERIC Educational Resources Information Center

Kirby, Douglas; And Others

For two decades, school-based clinics have been providing basic health care to medically underserved teenagers and addressing the increasingly complex health and social problems facing young people, particularly unintended pregnancy. Today there are 150 school-based clinics operating in most major cities and many rural areas. In 1984, the Center…

Evaluating Evidence-Informed Clinical Reasoning Proficiency in Oral Practical Examinations

ERIC Educational Resources Information Center

Geisler, Paul R.; Hummel, Chris; Piebes, Sarah

2014-01-01

Clinical reasoning is the specific cognitive process used by health care practitioners to formulate accurate diagnoses for complex patient problems and to set up and carry out effective care. Athletic training students and practitioners need to develop and display effective clinical reasoning skills in the assessment of injury and illness as a…

Developing a case mix classification for child and adolescent mental health services: the influence of presenting problems, complexity factors and service providers on number of appointments.

PubMed

Martin, Peter; Davies, Roger; Macdougall, Amy; Ritchie, Benjamin; Vostanis, Panos; Whale, Andy; Wolpert, Miranda

2017-09-01

Case-mix classification is a focus of international attention in considering how best to manage and fund services, by providing a basis for fairer comparison of resource utilization. Yet there is little evidence of the best ways to establish case mix for child and adolescent mental health services (CAMHS). To develop a case mix classification for CAMHS that is clinically meaningful and predictive of number of appointments attended and to investigate the influence of presenting problems, context and complexity factors and provider variation. We analysed 4573 completed episodes of outpatient care from 11 English CAMHS. Cluster analysis, regression trees and a conceptual classification based on clinical best practice guidelines were compared regarding their ability to predict number of appointments, using mixed effects negative binomial regression. The conceptual classification is clinically meaningful and did as well as data-driven classifications in accounting for number of appointments. There was little evidence for effects of complexity or context factors, with the possible exception of school attendance problems. Substantial variation in resource provision between providers was not explained well by case mix. The conceptually-derived classification merits further testing and development in the context of collaborative decision making.

Improving the simple, complicated and complex realities of community-acquired pneumonia.

PubMed

Liu, S K; Homa, K; Butterly, J R; Kirkland, K B; Batalden, P B

2009-04-01

This paper first describes efforts to improve the care for patients hospitalised with community-acquired pneumonia and the associated changes in quality measures at a rural academic medical centre. The results of the improvement interventions and the associated clinical realities, expected outcomes, measures, improvement interventions and improvement aims are then re-examined using the Glouberman and Zimmerman typology of healthcare problems--simple, complicated and complex. The typology is then used to explore the future design and assessment of improvement interventions, which may allow better matching with the types of problem healthcare providers and organisations are confronted with. Matching improvement interventions with problem category has the possibility of improving the success of improvement efforts and the reliability of care while at the same time preserving needed provider autonomy and judgement to adapt care for more complex problems.

Clinical complexity and Occam's razor: navigating between Scylla and Charibdy of the geriatric practice. A case of secondary hypertension in a very old patient.

PubMed

Turco, Renato; Torpilliesi, Tiziana; Morghen, Sara; Bellelli, Giuseppe; Trabucchi, Marco

2009-05-01

The clinical approach toward elderly patients is often very complex and associated with an increased risk of medical errors. This case report is an example of how various objective (related to patient) and subjective (related to physicians) factors may influence the optimal diagnostic approach in elderly frail patients. We also discuss geriatric practice, which must be characterized by the intellectual honesty to refuse any sort of prejudices (such as ageism) and by the skill to navigate between the Scylla (ie, viewing clinical problems as unrelated to each other) and the Charibdy (ie, applying the Occam's razor principle) of the patient's complexity.

A new approach to identify, classify and count drugrelated events

PubMed Central

Bürkle, Thomas; Müller, Fabian; Patapovas, Andrius; Sonst, Anja; Pfistermeister, Barbara; Plank-Kiegele, Bettina; Dormann, Harald; Maas, Renke

2013-01-01

Aims The incidence of clinical events related to medication errors and/or adverse drug reactions reported in the literature varies by a degree that cannot solely be explained by the clinical setting, the varying scrutiny of investigators or varying definitions of drug-related events. Our hypothesis was that the individual complexity of many clinical cases may pose relevant limitations for current definitions and algorithms used to identify, classify and count adverse drug-related events. Methods Based on clinical cases derived from an observational study we identified and classified common clinical problems that cannot be adequately characterized by the currently used definitions and algorithms. Results It appears that some key models currently used to describe the relation of medication errors (MEs), adverse drug reactions (ADRs) and adverse drug events (ADEs) can easily be misinterpreted or contain logical inconsistencies that limit their accurate use to all but the simplest clinical cases. A key limitation of current models is the inability to deal with complex interactions such as one drug causing two clinically distinct side effects or multiple drugs contributing to a single clinical event. Using a large set of clinical cases we developed a revised model of the interdependence between MEs, ADEs and ADRs and extended current event definitions when multiple medications cause multiple types of problems. We propose algorithms that may help to improve the identification, classification and counting of drug-related events. Conclusions The new model may help to overcome some of the limitations that complex clinical cases pose to current paper- or software-based drug therapy safety. PMID:24007453

Cynefin as Reference Framework to Facilitate Insight and Decision-Making in Complex Contexts of Biomedical Research.

PubMed

Kempermann, Gerd

2017-01-01

The Cynefin scheme is a concept of knowledge management, originally devised to support decision making in management, but more generally applicable to situations, in which complexity challenges the quality of insight, prediction, and decision. Despite the fact that life itself, and especially the brain and its diseases, are complex to the extent that complexity could be considered their cardinal feature, complex problems in biomedicine are often treated as if they were actually not more than the complicated sum of solvable sub-problems. Because of the emergent properties of complex contexts this is not correct. With a set of clear criteria Cynefin helps to set apart complex problems from "simple/obvious," "complicated," "chaotic," and "disordered" contexts in order to avoid misinterpreting the relevant causality structures. The distinction comes with the insight, which specific kind of knowledge is possible in each of these categories and what are the consequences for resulting decisions and actions. From student's theses over the publication and grant writing process to research politics, misinterpretation of complexity can have problematic or even dangerous consequences, especially in clinical contexts. Conceptualization of problems within a straightforward reference language like Cynefin improves clarity and stringency within projects and facilitates communication and decision-making about them.

Integrative Treatment in Persons with Intellectual Disability and Mental Health Problems

ERIC Educational Resources Information Center

Dosen, A.

2007-01-01

Background: Clinical experience has proven thus far that a monodisciplinary treatment approach to behavioural and psychiatric problems in persons with intellectual disability (ID), such as psychotropic medication or behaviour modification programmes, has yielded limited success. It is clear that the complexity of behavioural and psychiatric…

Schizophrenia, narrative, and neurocognition: The utility of life-stories in understanding social problem-solving skills.

PubMed

Moe, Aubrey M; Breitborde, Nicholas J K; Bourassa, Kyle J; Gallagher, Colin J; Shakeel, Mohammed K; Docherty, Nancy M

2018-06-01

Schizophrenia researchers have focused on phenomenological aspects of the disorder to better understand its underlying nature. In particular, development of personal narratives-that is, the complexity with which people form, organize, and articulate their "life stories"-has recently been investigated in individuals with schizophrenia. However, less is known about how aspects of narrative relate to indicators of neurocognitive and social functioning. The objective of the present study was to investigate the association of linguistic complexity of life-story narratives to measures of cognitive and social problem-solving abilities among people with schizophrenia. Thirty-two individuals with a diagnosis of schizophrenia completed a research battery consisting of clinical interviews, a life-story narrative, neurocognitive testing, and a measure assessing multiple aspects of social problem solving. Narrative interviews were assessed for linguistic complexity using computerized technology. The results indicate differential relationships of linguistic complexity and neurocognition to domains of social problem-solving skills. More specifically, although neurocognition predicted how well one could both describe and enact a solution to a social problem, linguistic complexity alone was associated with accurately recognizing that a social problem had occurred. In addition, linguistic complexity appears to be a cognitive factor that is discernible from other broader measures of neurocognition. Linguistic complexity may be more relevant in understanding earlier steps of the social problem-solving process than more traditional, broad measures of cognition, and thus is relevant in conceptualizing treatment targets. These findings also support the relevance of developing narrative-focused psychotherapies. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Reflecting on the essence of our problem-based learning discussions: the importance of faculty development and our continuous quest for applications of problem-based learning.

PubMed

Chan, Engle Angela

2009-05-01

While problem-based learning (PBL) is a teaching strategy to promote critical thinking, creativity and self-directedness in learning is very important. It is the meaning of the learning, with a contextual understanding, that marks the significance of this approach in our healthcare education. At the 2008 Kaohsiung Medical University International Conference and Workshop on PBL, the scholarly discourse on sharing empirical findings and practical experience with various aspects of PBL brought forth the importance of the teachers' continued learning about the meaning, the dynamics of the process, and the pragmatic details of PBL. This quest for a continuous learning and understanding about PBL parallels our search to extend the classroom PBL into students' clinical experience. The development of clinical teachers in the understanding of PBL was explored as part of their experiential learning in clinical teaching after their PBL workshops. While the clinical teachers who participated in the project appreciated the merits of clinical PBL, the complex balance between patient service and student teaching--in an unpredictable clinical setting--has led to the use of a simulated clinical environment with simulated patients. We also piloted PBL for interprofessional education of undergraduate students of nursing and social work. The ways we can adopt PBL in various settings with different intents will help prepare our healthcare graduates in meeting the challenges of our ever more complex healthcare systems, and the demands of holistic patient care.

[Patient-related complexity in nursing care - Collective case studies in the acute care hospital].

PubMed

Gurtner, Caroline; Spirig, Rebecca; Staudacher, Diana; Huber, Evelyn

2018-06-04

Patient-related complexity in nursing care - Collective case studies in the acute care hospital Abstract. Patient-related complexity of nursing is defined by the three characteristics "instability", "uncertainty", and "variability". Complexity increased in the past years, due to reduced hospital length of stay and a growing number of patients with chronic and multiple diseases. We investigated the phenomenon of patient-related complexity from the point of view of nurses and clinical nurse specialists in an acute care hospital. In the context of a collective case study design, nurses and clinical nurse specialists assessed the complexity of nursing situations with a questionnaire. Subsequently, we interviewed nurses and clinical nurse specialists about their evaluation of patient-related complexity. In a within-case-analysis we summarized data inductively to create case narratives. By means of a cross-case-analysis we compared the cases with regard to deductively derived characteristics. The four cases exemplarily showed that the degree of complexity depends on the controllability and predictability of clinical problems. Additionally, complexity increases or decreases, according to patients' individual resources. Complex patient situations demand professional expertise, experience, communicative competencies and the ability for reflection. Beginner nurses would benefit from support and advice by experienced nurses to develop these skills.

Development of an exercise intervention for the prevention of musculoskeletal shoulder problems after breast cancer treatment: the prevention of shoulder problems trial (UK PROSPER).

PubMed

Richmond, Helen; Lait, Clare; Srikesavan, Cynthia; Williamson, Esther; Moser, Jane; Newman, Meredith; Betteley, Lauren; Fordham, Beth; Rees, Sophie; Lamb, Sarah E; Bruce, Julie

2018-06-18

Musculoskeletal shoulder problems are common after breast cancer treatment. There is some evidence to suggest that early postoperative exercise is safe and may improve shoulder function. We describe the development and delivery of a complex intervention for evaluation within a randomised controlled trial (RCT), designed to target prevention of musculoskeletal shoulder problems after breast cancer surgery (The Prevention of Shoulder Problems Trial; PROSPER). A pragmatic, multicentre RCT to compare the clinical and cost-effectiveness of best practice usual care versus a physiotherapy-led exercise and behavioural support intervention in women at high risk of shoulder problems after breast cancer treatment. PROSPER will recruit 350 women from approximately 15 UK centres, with follow-up at 6 and 12 months. The primary outcome is shoulder function at 12 months; secondary outcomes include postoperative pain, health related quality of life, adverse events and healthcare resource use. A multi-phased approach was used to develop the PROSPER intervention which was underpinned by existing evidence and modified for implementation after input from clinical experts and women with breast cancer. The intervention was tested and refined further after qualitative interviews with patients newly diagnosed with breast cancer; a pilot RCT was then conducted at three UK clinical centres. The PROSPER intervention incorporates three main components: shoulder-specific exercises targeting range of movement and strength; general physical activity; and behavioural strategies to encourage adherence and support exercise behaviour. The final PROSPER intervention is fully manualised with clear, documented pathways for clinical assessment, exercise prescription, use of behavioural strategies, and with guidance for treatment of postoperative complications. This paper adheres to TIDieR and CERT recommendations for the transparent, comprehensive and explicit reporting of complex interventions. International Standard Randomised Controlled Trial Number: ISRCTN 35358984 .

Clinical decision making-a functional medicine perspective.

PubMed

Pizzorno, Joseph E

2012-09-01

As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care.

Clinical Decision Making—A Functional Medicine Perspective

PubMed Central

2012-01-01

As 21st century health care moves from a disease-based approach to a more patient-centric system that can address biochemical individuality to improve health and function, clinical decision making becomes more complex. Accentuating the problem is the lack of a clear standard for this more complex functional medicine approach. While there is relatively broad agreement in Western medicine for what constitutes competent assessment of disease and identification of related treatment approaches, the complex functional medicine model posits multiple and individualized diagnostic and therapeutic approaches, most or many of which have reasonable underlying science and principles, but which have not been rigorously tested in a research or clinical setting. This has led to non-rigorous thinking and sometimes to uncritical acceptance of both poorly documented diagnostic procedures and ineffective therapies, resulting in less than optimal clinical care. PMID:24278827

Assessment of Competence in Clinical Reasoning and Decision-Making under Uncertainty: The Script Concordance Test Method

ERIC Educational Resources Information Center

Ramaekers, Stephan; Kremer, Wim; Pilot, Albert; van Beukelen, Peter; van Keulen, Hanno

2010-01-01

Real-life, complex problems often require that decisions are made despite limited information or insufficient time to explore all relevant aspects. Incorporating authentic uncertainties into an assessment, however, poses problems in establishing results and analysing their methodological qualities. This study aims at developing a test on clinical…

The clinical management of diabetic foot in the elderly and medico-legal implications.

PubMed

Terranova, Claudio; Bruttocao, Andrea

2013-10-01

Diabetic foot is a complex and challenging pathological state, characterized by high complexity of management, morbidity and mortality. The elderly present peculiar problems which interfere on one hand with the patient's compliance and on the other with their diagnostic-therapeutic management. Difficult clinical management may result in medico-legal problems, with criminal and civil consequences. In this context, the authors present a review of the literature, analysing aspects concerning the diagnosis and treatment of diabetic foot in the elderly which may turn out to be a source of professional responsibility. Analysis of these aspects provides an opportunity to discuss elements important not only for clinicians and medical workers but also experts (judges, lawyers, medico-legal experts) who must evaluate hypotheses of professional responsibility concerning diabetic foot in the elderly.

Child Obesity and Mental Health: A Complex Interaction.

PubMed

Small, Leigh; Aplasca, Alexis

2016-04-01

Prevalence rates of childhood obesity have risen steeply over the last 3 decades. Given the increased national focus, the frequency of this clinical problem, and the multiple mental health factors that coexist with it, make obesity a public health concern. The complex relationships between mental health and obesity serve to potentiate the severity and interdependency of each. The purpose of this review is to create a contextual connection for the 2 conditions as outlined by the research literature and consider treatment options that affect both health problems. Copyright © 2016 Elsevier Inc. All rights reserved.

Heading off boundary problems: clinical supervision as risk management.

PubMed

Walker, R; Clark, J J

1999-11-01

The effective management of risk in clinical practice includes steps to limit harm to clients resulting from ethical violations or professional misconduct. Boundary problems constitute some of the most damaging ethical violations. The authors propose an active use of clinical supervision to anticipate and head off possible ethical violations by intervening when signs of boundary problems appear. The authors encourage a facilitative, Socratic method, rather than directive approaches, to help supervisees maximize their learning about ethical complexities. Building on the idea of a slippery slope, in which seemingly insignificant acts can lead to unethical patterns of behavior, the authors discuss ten cues to potential boundary problems, including strong feelings about a client; extended sessions with clients; gift giving between clinician and client; loans, barter, and sale of goods; clinician self-disclosures; and touching and sex. The authors outline supervisory interventions to be made when the cues are detected.

Clinical Correlations as a Tool in Basic Science Medical Education

PubMed Central

Klement, Brenda J.; Paulsen, Douglas F.; Wineski, Lawrence E.

2016-01-01

Clinical correlations are tools to assist students in associating basic science concepts with a medical application or disease. There are many forms of clinical correlations and many ways to use them in the classroom. Five types of clinical correlations that may be embedded within basic science courses have been identified and described. (1) Correlated examples consist of superficial clinical information or stories accompanying basic science concepts to make the information more interesting and relevant. (2) Interactive learning and demonstrations provide hands-on experiences or the demonstration of a clinical topic. (3) Specialized workshops have an application-based focus, are more specialized than typical laboratory sessions, and range in complexity from basic to advanced. (4) Small-group activities require groups of students, guided by faculty, to solve simple problems that relate basic science information to clinical topics. (5) Course-centered problem solving is a more advanced correlation activity than the others and focuses on recognition and treatment of clinical problems to promote clinical reasoning skills. Diverse teaching activities are used in basic science medical education, and those that include clinical relevance promote interest, communication, and collaboration, enhance knowledge retention, and help develop clinical reasoning skills. PMID:29349328

Informatics Tools to Improve Clinical Research

PubMed Central

Argraves, S; Brandt, CA; Money, R; Nadkarni, P

2005-01-01

During the conduct of complex clinical trials, there are numerous sources and types of data collection and project coordination problems. Methods and approaches to address the conduct of a trial vary in both the cost and time to perform and the potential benefit. Informatics tools can help trial coordinators and investigators ensure the collection of high quality research data during all phases of a clinical trial. PMID:16779170

Conceptual and procedural knowledge community college students use when solving a complex science problem

NASA Astrophysics Data System (ADS)

Steen-Eibensteiner, Janice Lee

2006-07-01

A strong science knowledge base and problem solving skills have always been highly valued for employment in the science industry. Skills currently needed for employment include being able to problem solve (Overtoom, 2000). Academia also recognizes the need for effectively teaching students to apply problem solving skills in clinical settings. This thesis investigates how students solve complex science problems in an academic setting in order to inform the development of problem solving skills for the workplace. Students' use of problem solving skills in the form of learned concepts and procedural knowledge was studied as students completed a problem that might come up in real life. Students were taking a community college sophomore biology course, Human Anatomy & Physiology II. The problem topic was negative feedback inhibition of the thyroid and parathyroid glands. The research questions answered were (1) How well do community college students use a complex of conceptual knowledge when solving a complex science problem? (2) What conceptual knowledge are community college students using correctly, incorrectly, or not using when solving a complex science problem? (3) What problem solving procedural knowledge are community college students using successfully, unsuccessfully, or not using when solving a complex science problem? From the whole class the high academic level participants performed at a mean of 72% correct on chapter test questions which was a low average to fair grade of C-. The middle and low academic participants both failed (F) the test questions (37% and 30% respectively); 29% (9/31) of the students show only a fair performance while 71% (22/31) fail. From the subset sample population of 2 students each from the high, middle, and low academic levels selected from the whole class 35% (8/23) of the concepts were used effectively, 22% (5/23) marginally, and 43% (10/23) poorly. Only 1 concept was used incorrectly by 3/6 of the students and identified as a misconception. One of 21 (5%) problem-solving pathway characteristics was used effectively, 7 (33%) marginally, and 13 (62%) poorly. There were very few (0 to 4) problem-solving pathway characteristics used unsuccessfully most were simply not used.

Systems and complexity thinking in general practice: part 1 - clinical application.

PubMed

Sturmberg, Joachim P

2007-03-01

Many problems encountered in general practice cannot be sufficiently explained within the Newtonian reductionist paradigm. Systems and complexity thinking - already widely adopted in most nonmedical disciplines - describes and explores the contextual nature of questions posed in medicine, and in general practice in particular. This article briefly describes the framework underpinning systems and complexity sciences. A case study illustrates how systems and complexity thinking can help to better understand the contextual nature of patient presentations, and how different approaches will lead to different outcomes.

Critical Thinking and Clinical Judgment in Novice Registered Nurses

ERIC Educational Resources Information Center

Tyne, Sheila L.

2018-01-01

The health care field has become increasingly more complex, requiring new nurses to be prepared upon graduation to respond to a variety of complex situations. Unfortunately, many graduates from associate degree nursing (ADN) programs are not able to think critically upon entering the work force. This presents a major problem for the nurse and for…

An approach to complex acid-base problems

PubMed Central

Herd, Anthony M.

2005-01-01

OBJECTIVE To review rules and formulas for solving even the most complex acid-base problems. SOURCES OF INFORMATION MEDLINE was searched from January 1966 to December 2003. The search was limited to English-language review articles involving human subjects. Nine relevant review papers were found and provide the background. As this information is well established and widely accepted, it is not judged for strength of evidence, as is standard practice. MAIN MESSAGE An understanding of the body’s responses to acidemia or alkalemia can be gained through a set of four rules and two formulas that can be used to interpret almost any acid-base problems. Physicians should, however, remember the “golden rule” of acid-base interpretation: always look at a patient’s clinical condition. CONCLUSION Physicians practising in acute care settings commonly encounter acid-base disturbances. While some of these are relatively simple and easy to interpret, some are more complex. Even complex cases can be resolved using the four rules and two formulas. PMID:15751566

Improving medication safety and diabetes management in Hong Kong: a multidisciplinary approach.

PubMed

Chung, A Ys; Anand, S; Wong, I Ck; Tan, K Cb; Wong, C Ff; Chui, W Cm; Chan, E W

2017-04-01

Patients with diabetes often require complex medication regimens. The positive impact of pharmacists on improving diabetes management or its co-morbidities has been recognised worldwide. This study aimed to characterise drug-related problems among diabetic patients in Hong Kong and their clinical significance, and to explore the role of pharmacists in the multidisciplinary diabetes management team by evaluating the outcome of their clinical interventions. An observational study was conducted at the Diabetes Clinic of a public hospital in Hong Kong from October 2012 to March 2014. Following weekly screening, and prior to the doctor's consultation, selected high-risk patients were interviewed by a pharmacist for medication reconciliation and review. Drug-related problems were identified and documented by the pharmacist who presented clinical recommendations to doctors to optimise a patient's drug regimen and resolve or prevent potential drug-related problems. A total of 522 patients were analysed and 417 drug-related problems were identified. The incidence of patients with drug-related problems was 62.8% with a mean of 0.9 (standard deviation, 0.6) drug-related problems per patient. The most common categories of drug-related problems were associated with dosing (43.9%), drug choice (17.3%), and non-allergic adverse reactions (15.6%). Drugs most frequently involved targeted the endocrine or cardiovascular system. The majority (71.9%) of drug-related problems were of moderate clinical significance and 28.1% were considered minor problems. Drug-related problems were totally solved (50.1%) and partially solved (11.0%) by doctors' acceptance of pharmacist recommendations, or received acknowledgement from doctors (5.5%). Pharmacists, in collaboration with the multidisciplinary team, demonstrated a positive impact by identifying, resolving, and preventing drug-related problems in patients with diabetes. Further plans for sustaining pharmacy service in the Diabetes Clinic would enable further studies to explore the long-term impact of pharmacists in improving patients' clinical outcomes in diabetes management.

Imaging in the assessment and management of athletic pubalgia.

PubMed

Robinson, Philip; Bhat, Vineet; English, Bryan

2011-02-01

This article reviews the clinical, anatomical, and biomechanical basis of pubalgia and relates it to the potential imaging findings and subsequent management. Although the magnetic resonance imaging features typically seen in symptomatic athletes are emphasized, this condition remains a complex clinical problem, and treatment addressing the functional rehabilitation of the entire region is highlighted. © Thieme Medical Publishers.

Predictive value of general movements' quality in low-risk infants for minor neurological dysfunction and behavioural problems at preschool age.

PubMed

Bennema, Anne N; Schendelaar, Pamela; Seggers, Jorien; Haadsma, Maaike L; Heineman, Maas Jan; Hadders-Algra, Mijna

2016-03-01

General movement (GM) assessment is a well-established tool to predict cerebral palsy in high-risk infants. Little is known on the predictive value of GM assessment in low-risk populations. To assess the predictive value of GM quality in early infancy for the development of the clinically relevant form of minor neurological dysfunction (complex MND) and behavioral problems at preschool age. Prospective cohort study. A total of 216 members of the prospective Groningen Assisted Reproductive Techniques (ART) cohort study were included in this study. ART did not affect neurodevelopmental outcome of these relatively low-risk infants born to subfertile parents. GM quality was determined at 2 weeks and 3 months. At 18 months and 4 years, the Hempel neurological examination was used to assess MND. At 4 years, parents completed the Child Behavior Checklist; this resulted in the total problem score (TPS), internalizing problem score (IPS), and externalizing problem score (EPS). Predictive values of definitely (DA) and mildly (MA) abnormal GMs were calculated. DA GMs at 2 weeks were associated with complex MND at 18 months and atypical TPS and IPS at 4 years (all p<0.05). Sensitivity and positive predictive value of DA GMs at 2 weeks were rather low (13%-60%); specificity and negative predictive value were excellent (92%-99%). DA GMs at 3 months occurred too infrequently to calculate prediction. MA GMs were not associated with outcome. GM quality as a single predictor for complex MND and behavioral problems at preschool age has limited clinical value in children at low risk for developmental disorders. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Big-Data Based Decision-Support Systems to Improve Clinicians' Cognition.

PubMed

Roosan, Don; Samore, Matthew; Jones, Makoto; Livnat, Yarden; Clutter, Justin

2016-01-01

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians' cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems.

Big-Data Based Decision-Support Systems to Improve Clinicians’ Cognition

PubMed Central

Roosan, Don; Samore, Matthew; Jones, Makoto; Livnat, Yarden; Clutter, Justin

2016-01-01

Complex clinical decision-making could be facilitated by using population health data to inform clinicians. In two previous studies, we interviewed 16 infectious disease experts to understand complex clinical reasoning. For this study, we focused on answers from the experts on how clinical reasoning can be supported by population-based Big-Data. We found cognitive strategies such as trajectory tracking, perspective taking, and metacognition has the potential to improve clinicians’ cognition to deal with complex problems. These cognitive strategies could be supported by population health data, and all have important implications for the design of Big-Data based decision-support tools that could be embedded in electronic health records. Our findings provide directions for task allocation and design of decision-support applications for health care industry development of Big data based decision-support systems. PMID:27990498

Variables influencing presenting symptoms of patients with eating disorders at psychiatric outpatient clinics.

PubMed

Tseng, Mei-Chih Meg; Chen, Kuan-Yu; Chang, Chin-Hao; Liao, Shih-Cheng; Chen, Hsi-Chung

2016-04-30

Eating disorders (EDs) have been underdiagnosed in many clinical settings. This study investigates the influence of clinical characteristics on presenting symptoms of patients with EDs. Psychiatric outpatients, aged 18-45, were enrolled sequentially and received a two-phase survey for EDs in August 2010-January 2013. Their primary reasons for seeking psychiatric help were obtained at their first encounter with outpatient psychiatrists. Patients' clinical and demographic characteristics were compared according to presenting symptoms with or without eating/weight problems. Of 2140 patients, 348 (16.3%) were diagnosed with an ED (22.6% of women and 6.3% of men). The three most common reasons for seeking psychiatric help were eating/weight problems (46.0%), emotional problems (41.3%), and sleep disturbances (19.3%). The multivariate analyses suggest that when patients with EDs presented symptoms that were less related to eating/weight problems, they were significantly more likely to be those having diagnoses other than anorexia nervosa or bulimia nervosa and less severe degree of binge-eating. Further, patients with EDs who demonstrated more impulsive behaviors and poorer functioning were less likely to report their eating problems when visiting psychiatric clinics. Thus, ED should be assessed routinely in patients with complex psychopathology to facilitate comprehensive treatment. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Informatics tools to improve clinical research study implementation.

PubMed

Brandt, Cynthia A; Argraves, Stephanie; Money, Roy; Ananth, Gowri; Trocky, Nina M; Nadkarni, Prakash M

2006-04-01

There are numerous potential sources of problems when performing complex clinical research trials. These issues are compounded when studies are multi-site and multiple personnel from different sites are responsible for varying actions from case report form design to primary data collection and data entry. We describe an approach that emphasizes the use of a variety of informatics tools that can facilitate study coordination, training, data checks and early identification and correction of faulty procedures and data problems. The paper focuses on informatics tools that can help in case report form design, procedures and training and data management. Informatics tools can be used to facilitate study coordination and implementation of clinical research trials.

A combined nurse-pharmacist managed pain clinic: joint venture of public and private sectors.

PubMed

Hadi, Muhammad Abdul; Alldred, David Phillip; Briggs, Michelle; Closs, S José

2012-02-01

Chronic pain has become one of the most prevalent problems in primary care. The management of chronic pain is complex and often requires a multidisciplinary approach. The limited capacity of general practitioners to manage chronic pain and long waiting time for secondary care referrals further add to the complexity of chronic pain management. Restricted financial and skilled human capital make it hard for healthcare systems across the world to establish and maintain multidisciplinary pain clinics, in spite of their documented effectiveness. Affordability and accessibility to such multidisciplinary pain clinics is often problematic for patients. The purpose of this paper is to share our experience and relevant research evidence of a community based combined nurse-pharmacist managed pain clinic. The pain clinic serves as an example of public-private partnership in healthcare.

Agreement between parents and teachers on preschool children's behavior in a clinical sample with externalizing behavioral problems.

PubMed

Korsch, Franziska; Petermann, Franz

2014-10-01

An accurate interpretation of information obtained from multiple assessors is indispensible when complex diagnoses of behavioral problems in children need to be confirmed. The present study examined the similarity of parents and kindergarten teachers ratings on children's behavior in a sample of 160 preschool children (a clinical group including 80 children with externalizing behavioral problems and a matched control group including 80 children). Behavioral problems were assessed using the SDQ, and the DISYPS-II questionnaires for ADHD and conduct disorders. The results revealed low levels of parent-teacher agreement for their ratings on the children's behavior in both groups with the highest correlations in the non-clinical sample. Parent-teacher agreement did not differ significantly across the samples. Parent and teacher ratings correlated with the prevalence of externalizing disorders and were found to be almost independent of each other. The results highlight the importance of multiple informants and their independent influence within the diagnostic process.

Brain Dynamics: Methodological Issues and Applications in Psychiatric and Neurologic Diseases

NASA Astrophysics Data System (ADS)

Pezard, Laurent

The human brain is a complex dynamical system generating the EEG signal. Numerical methods developed to study complex physical dynamics have been used to characterize EEG since the mid-eighties. This endeavor raised several issues related to the specificity of EEG. Firstly, theoretical and methodological studies should address the major differences between the dynamics of the human brain and physical systems. Secondly, this approach of EEG signal should prove to be relevant for dealing with physiological or clinical problems. A set of studies performed in our group is presented here within the context of these two problematic aspects. After the discussion of methodological drawbacks, we review numerical simulations related to the high dimension and spatial extension of brain dynamics. Experimental studies in neurologic and psychiatric disease are then presented. We conclude that if it is now clear that brain dynamics changes in relation with clinical situations, methodological problems remain largely unsolved.

How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice: a social cognitive and affective neuroscience approach.

PubMed

Lanius, R A; Bluhm, R L; Frewen, P A

2011-11-01

In this review, we examine the relevance of the social cognitive and affective neuroscience (SCAN) paradigm for an understanding of the psychology and neurobiology of complex post-traumatic stress disorder (PTSD) and its effective treatment. The relevant literature pertaining to SCAN and PTSD was reviewed. We suggest that SCAN offers a novel theoretical paradigm for understanding psychological trauma and its numerous clinical outcomes, most notably problems in emotional/self-awareness, emotion regulation, social emotional processing and self-referential processing. A core set of brain regions appear to mediate these collective psychological functions, most notably the cortical midline structures, the amygdala, the insula, posterior parietal cortex and temporal poles, suggesting that problems in one area (e.g. emotional awareness) may relate to difficulties in another (e.g. self-referential processing). We further propose, drawing on clinical research, that the experiences of individuals with PTSD related to chronic trauma often reflect impairments in multiple social cognitive and affective functions. It is important that the assessment and treatment of individuals with complex PTSD not only addresses traumatic memories but also takes a SCAN-informed approach that focuses on the underlying deficits in emotional/self-awareness, emotion regulation, social emotional processing and self-referential processing. © 2011 John Wiley & Sons A/S.

Clinical medicine between science, ethics and economy: a complex activity.

PubMed

Federspil, Giovanni

2004-01-01

Until recently the common opinion was that medicine was substantially a natural science. In recent years, this has completely changed because two non-naturalistic disciplines have become part of the physician's activity; ethics and economy. These new disciplines have evidenced many problems to which doctors did not pay much attention before; however, they had an impact on the clinician's sensibility. At present, clinical medicine represents a complex knowledge as well as an activity: it is both a "historical" and a "technological" science characterized by a specific goal, the recovery or maintenance of health, and by a series of values.

[Ethics in clinical research: contextualizing and reductionist problem definitions, forms of ethical reflection and some particular implications].

PubMed

Roelcke, Volker

2003-12-01

The present paper starts off with a short outline of issues, conflicts, and goals of ethical reflection about clinical research. It is then argued that non-reductionist, patient-centred ethics should critically reflect on medically preformed problem definitions, ways of problem solution, and evaluations. The shortcomings of such preformed perceptions and interpretations are illustrated using the examples of dementia research, and the complexities of the notion of risk. A more comprehensive approach including the perceptions, interpretations, and evaluations of the patients' perspective necessitates a form of ethical reflection which takes into account the social and cultural contexts of clinical research, and which therefore relies on concepts and methods of the cultural sciences (in particular history, sociology, and cultural anthropology). The decision for a reductionist, or for a contextualising mode of ethical reflection represents in itself a value decision and needs to be explicitly justified.

The orthodontic-periodontic interrelationship in integrated treatment challenges: a systematic review.

PubMed

Gkantidis, N; Christou, P; Topouzelis, N

2010-05-01

Orthodontic treatment aims at providing an acceptable functional and aesthetic occlusion with appropriate tooth movements. These movements are strongly related to interactions of teeth with their supportive periodontal tissues. In recent years, because of the increased number of adult patients seeking orthodontic treatment, orthodontists frequently face patients with periodontal problems. Aesthetic considerations, like uneven gingival margins or functional problems resulting from inflammatory periodontal diseases should be considered in orthodontic treatment planning. Furthermore, in cases with severe periodontitis, orthodontics may improve the possibilities of saving and restoring a deteriorated dentition. In modern clinical practice, the contribution of the orthodontist, the periodontist and the general dentist is essential for optimized treatment outcomes. The purpose of this systematic review is to highlight the relationship between orthodontics and periodontics in clinical practice and to improve the level of cooperation between dental practitioners. Potentials and limitations that derive from the interdisciplinary approach of complex orthodontic-periodontal clinical problems are discussed.

Psychopathology in pediatric epilepsy: role of antiepileptic drugs.

PubMed

Caplan, Rochelle

2012-01-01

Children with epilepsy are usually treated with antiepileptic drugs (AEDS). Some AEDs adversely affect behavior in susceptible children. Since psychiatric comorbidity is prevalent in pediatric epilepsy, this paper attempts to disentangle these AED side effects from the psychopathology associated with this illness. It first outlines the clinical and methodological problems involved in determining if AEDs contribute to the behavior and emotional problems of children with epilepsy. It then presents research evidence for and against the role AEDs play in the psychopathology of children with epilepsy, and outlines how future studies might investigate this problem. A brief description of how to clinically separate out AED effects from the complex illness-related and psychosocial factors that contribute to the behavior difficulties of children with epilepsy concludes the paper.

Clinical application of three-dimensional printing to the management of complex univentricular hearts with abnormal systemic or pulmonary venous drainage.

PubMed

McGovern, Eimear; Kelleher, Eoin; Snow, Aisling; Walsh, Kevin; Gadallah, Bassem; Kutty, Shelby; Redmond, John M; McMahon, Colin J

2017-09-01

In recent years, three-dimensional printing has demonstrated reliable reproducibility of several organs including hearts with complex congenital cardiac anomalies. This represents the next step in advanced image processing and can be used to plan surgical repair. In this study, we describe three children with complex univentricular hearts and abnormal systemic or pulmonary venous drainage, in whom three-dimensional printed models based on CT data assisted with preoperative planning. For two children, after group discussion and examination of the models, a decision was made not to proceed with surgery. We extend the current clinical experience with three-dimensional printed modelling and discuss the benefits of such models in the setting of managing complex surgical problems in children with univentricular circulation and abnormal systemic or pulmonary venous drainage.

Learning to Leave: Problems of Graduating--Clinical Observations and Strategies.

ERIC Educational Resources Information Center

Margolis, Gary

1980-01-01

Graduating from college involves a series of complex psychological feelings and behaviors. Students experiencing stress as a result of impending graduation can be helped by counseling that takes into consideration the specific process of leaving college. (JN)

The Dreyfus model of clinical problem-solving skills acquisition: a critical perspective

PubMed Central

Peña, Adolfo

2010-01-01

Context The Dreyfus model describes how individuals progress through various levels in their acquisition of skills and subsumes ideas with regard to how individuals learn. Such a model is being accepted almost without debate from physicians to explain the ‘acquisition’ of clinical skills. Objectives This paper reviews such a model, discusses several controversial points, clarifies what kind of knowledge the model is about, and examines its coherence in terms of problem-solving skills. Dreyfus' main idea that intuition is a major aspect of expertise is also discussed in some detail. Relevant scientific evidence from cognitive science, psychology, and neuroscience is reviewed to accomplish these aims. Conclusions Although the Dreyfus model may partially explain the ‘acquisition’ of some skills, it is debatable if it can explain the acquisition of clinical skills. The complex nature of clinical problem-solving skills and the rich interplay between the implicit and explicit forms of knowledge must be taken into consideration when we want to explain ‘acquisition’ of clinical skills. The idea that experts work from intuition, not from reason, should be evaluated carefully. PMID:20563279

Social and cultural factors in the successful control of tuberculosis.

PubMed Central

Rubel, A J; Garro, L C

1992-01-01

The burden of tuberculosis on the public health is staggering. Worldwide, annual incidence of new cases is estimated to be about 8 million. Almost 3 million deaths occur yearly. Early case identification and adherence to treatment regimens are the remaining barriers to successful control. In many nations, however, fewer than half those with active disease receive a diagnosis, and fewer than half those beginning treatment complete it. The twin problems of delay in seeking treatment and abandonment of a prescribed regimen derive from complex factors. People's confusion as to the implications of the tuberculosis symptoms, costs of transportation to clinic services, the social stigma that attaches to tuberculosis, the high cost of medication, organizational problems in providing adequate followup services, and patients' perception of clinic facilities as inhospitable all contribute to the complexity. Sociocultural factors are emphasized in this report because hitherto they have not been adequately explored. Salient among those sociocultural factors is the health culture of the patients. That is, the understanding and information people have from family, friends, and neighbors as to the nature of a health problem, its cause, and its implications. A knowledge of the health culture of their patients has become a critical tool if tuberculosis control programs are to be successful. Several anthropological procedures are recommended to help uncover the health culture of people served by tuberculosis clinics. PMID:1454974

Contextualising eating problems in individual diet counselling.

PubMed

Kristensen, Søren T; Køster, Allan

2014-05-01

Health professionals consider diet to be a vital component in managing weight, chronic diseases and the overall promotion of health. This article takes the position that the complexity and contextual nature of individual eating problems needs to be addressed in a more systematic and nuanced way than is usually the case in diet counselling, motivational interviewing and health coaching. We suggest the use of narrative practice as a critical and context-sensitive counselling approach to eating problems. Principles of externalisation and co-researching are combined within a counselling framework that employs logistic, social and discursive eating problems as analytic categories. Using cases from a health clinic situated at the Metropolitan University College in Copenhagen, we show that even if the structural conditions associated with eating problems may not be solvable through individual counselling sessions, exploration of the complex structures of food and eating with the client can provide agency by helping them navigate within the context of the problem. We also exemplify why a reflexive and critical approach to the way health is perceived by clients should be an integrated part of diet counselling.

The "Performance of Rotavirus and Oral Polio Vaccines in Developing Countries" (PROVIDE) study: description of methods of an interventional study designed to explore complex biologic problems.

PubMed

Kirkpatrick, Beth D; Colgate, E Ross; Mychaleckyj, Josyf C; Haque, Rashidul; Dickson, Dorothy M; Carmolli, Marya P; Nayak, Uma; Taniuchi, Mami; Naylor, Caitlin; Qadri, Firdausi; Ma, Jennie Z; Alam, Masud; Walsh, Mary Claire; Diehl, Sean A; Petri, William A

2015-04-01

Oral vaccines appear less effective in children in the developing world. Proposed biologic reasons include concurrent enteric infections, malnutrition, breast milk interference, and environmental enteropathy (EE). Rigorous study design and careful data management are essential to begin to understand this complex problem while assuring research subject safety. Herein, we describe the methodology and lessons learned in the PROVIDE study (Dhaka, Bangladesh). A randomized clinical trial platform evaluated the efficacy of delayed-dose oral rotavirus vaccine as well as the benefit of an injectable polio vaccine replacing one dose of oral polio vaccine. This rigorous infrastructure supported the additional examination of hypotheses of vaccine underperformance. Primary and secondary efficacy and immunogenicity measures for rotavirus and polio vaccines were measured, as well as the impact of EE and additional exploratory variables. Methods for the enrollment and 2-year follow-up of a 700 child birth cohort are described, including core laboratory, safety, regulatory, and data management practices. Intense efforts to standardize clinical, laboratory, and data management procedures in a developing world setting provide clinical trials rigor to all outcomes. Although this study infrastructure requires extensive time and effort, it allows optimized safety and confidence in the validity of data gathered in complex, developing country settings. © The American Society of Tropical Medicine and Hygiene.

Improving the learning of clinical reasoning through computer-based cognitive representation.

PubMed

Wu, Bian; Wang, Minhong; Johnson, Janice M; Grotzer, Tina A

2014-01-01

Objective Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Methods Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. Results A significant improvement was found in students' learning products from the beginning to the end of the study, consistent with students' report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. Conclusions The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction.

Improving the learning of clinical reasoning through computer-based cognitive representation

PubMed Central

Wu, Bian; Wang, Minhong; Johnson, Janice M.; Grotzer, Tina A.

2014-01-01

Objective Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Methods Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. Results A significant improvement was found in students’ learning products from the beginning to the end of the study, consistent with students’ report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. Conclusions The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction. PMID:25518871

Improving the learning of clinical reasoning through computer-based cognitive representation.

PubMed

Wu, Bian; Wang, Minhong; Johnson, Janice M; Grotzer, Tina A

2014-01-01

Clinical reasoning is usually taught using a problem-solving approach, which is widely adopted in medical education. However, learning through problem solving is difficult as a result of the contextualization and dynamic aspects of actual problems. Moreover, knowledge acquired from problem-solving practice tends to be inert and fragmented. This study proposed a computer-based cognitive representation approach that externalizes and facilitates the complex processes in learning clinical reasoning. The approach is operationalized in a computer-based cognitive representation tool that involves argument mapping to externalize the problem-solving process and concept mapping to reveal the knowledge constructed from the problems. Twenty-nine Year 3 or higher students from a medical school in east China participated in the study. Participants used the proposed approach implemented in an e-learning system to complete four learning cases in 4 weeks on an individual basis. For each case, students interacted with the problem to capture critical data, generate and justify hypotheses, make a diagnosis, recall relevant knowledge, and update their conceptual understanding of the problem domain. Meanwhile, students used the computer-based cognitive representation tool to articulate and represent the key elements and their interactions in the learning process. A significant improvement was found in students' learning products from the beginning to the end of the study, consistent with students' report of close-to-moderate progress in developing problem-solving and knowledge-construction abilities. No significant differences were found between the pretest and posttest scores with the 4-week period. The cognitive representation approach was found to provide more formative assessment. The computer-based cognitive representation approach improved the learning of clinical reasoning in both problem solving and knowledge construction.

[Clinical decision making and critical thinking in the nursing diagnostic process].

PubMed

Müller-Staub, Maria

2006-10-01

The daily routine requires complex thinking processes of nurses, but clinical decision making and critical thinking are underestimated in nursing. A great demand for educational measures in clinical judgement related with the diagnostic process was found in nurses. The German literature hardly describes nursing diagnoses as clinical judgements about human reactions on health problems / life processes. Critical thinking is described as an intellectual, disciplined process of active conceptualisation, application and synthesis of information. It is gained through observation, experience, reflection and communication and leads thinking and action. Critical thinking influences the aspects of clinical decision making a) diagnostic judgement, b) therapeutic reasoning and c) ethical decision making. Human reactions are complex processes and in their course, human behavior is interpreted in the focus of health. Therefore, more attention should be given to the nursing diagnostic process. This article presents the theoretical framework of the paper "Clinical decision making: Fostering critical thinking in the nursing diagnostic process through case studies".

Kaizen practice in healthcare: a qualitative analysis of hospital employees' suggestions for improvement

PubMed Central

Mazzocato, Pamela; Stenfors-Hayes, Terese; von Thiele Schwarz, Ulrica; Hasson, Henna

2016-01-01

Objectives Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this study is to describe the types of issues and improvement suggestions that hospital employees feel empowered to address through kaizen practices in order to understand when and how kaizen is used in healthcare. Methods We analysed 186 structured kaizen documents containing improvement suggestions that were produced by 165 employees at a Swedish hospital. Directed content analysis was used to categorise the suggestions into following categories: type of situation (proactive or reactive) triggering an action; type of process addressed (technical/administrative, support and clinical); complexity level (simple or complex); and type of outcomes aimed for (operational or sociotechnical). Compliance to the kaizen template was calculated. Results 72% of the improvement suggestions were reactions to a perceived problem. Support, technical and administrative, and primary clinical processes were involved in 47%, 38% and 16% of the suggestions, respectively. The majority of the kaizen documents addressed simple situations and focused on operational outcomes. The degree of compliance to the kaizen template was high for several items concerning the identification of problems and the proposed solutions, and low for items related to the test and implementation of solutions. Conclusions There is a need to combine kaizen practices with improvement and innovation practices that help staff and managers to address complex issues, such as the improvement of clinical care processes. The limited focus on sociotechnical aspects and the partial compliance to kaizen templates may indicate a limited understanding of the entire kaizen process and of how it relates to the overall organisational goals. This in turn can hamper the sustainability of kaizen practices and results. PMID:27473953

When trust is threatened: Qualitative study of parents' perspectives on problematic clinical relationships in child cancer care

PubMed Central

Davies, Sarah; Salmon, Peter

2017-01-01

Abstract Objective We explored parents' accounts of the parent‐clinician relationship in childhood cancer to understand how parents who perceive threats to the relationship can be supported. Methods Multicentre longitudinal qualitative study, with 67 UK parents of children (aged 1‐12 years) receiving treatment for acute lymphoblastic leukaemia. Analyses drew on the wider sample but focussed on 50 semistructured interviews with 20 parents and were informed by constant comparison. Results All 20 parents described problems with clinical care such as inadequate information or mistakes by staff but varied in how much the problems threatened their sense of relationship with clinicians. Some parents saw the problems as having no relevance to the parent‐clinician relationship. Others saw the problems as threats to the clinical relationship but worked to “contain” the threat in ways that preserved a trusting relationship with at least one senior clinician. Parents' containment work protected the security they needed from the parent‐clinician relationship, but containment was a tenuous process for some. A few parents were unable to contain the problems at all; lacking trust in clinicians, these parents suffered considerably. Conclusions Given the complexity of childhood cancer care, problems with clinical care are inevitable. By engaging in containment work, parents met their needs to feel secure in the face of these problems, but the extent to which parents should have to do this work is debatable. Parents could benefit from support to seek help when problems arise which threaten their trust in clinicians. Attachment theory can guide clinicians in giving this support. PMID:28494129

Methods and means of diagnostics of oncological diseases on the basis of pattern recognition: intelligent morphological systems - problems and solutions

NASA Astrophysics Data System (ADS)

Nikitaev, V. G.

2017-01-01

The development of methods of pattern recognition in modern intelligent systems of clinical cancer diagnosis are discussed. The histological (morphological) diagnosis - primary diagnosis for medical setting with cancer are investigated. There are proposed: interactive methods of recognition and structure of intellectual morphological complexes based on expert training-diagnostic and telemedicine systems. The proposed approach successfully implemented in clinical practice.

Differentiating the mTOR inhibitors everolimus and sirolimus in the treatment of tuberous sclerosis complex

PubMed Central

MacKeigan, Jeffrey P.; Krueger, Darcy A.

2015-01-01

Tuberous sclerosis complex (TSC) is a genetic autosomal dominant disorder characterized by benign tumor-like lesions, called hamartomas, in multiple organ systems, including the brain, skin, heart, kidneys, and lung. These hamartomas cause a diverse set of clinical problems based on their location and often result in epilepsy, learning difficulties, and behavioral problems. TSC is caused by mutations within the TSC1 or TSC2 genes that inactivate the genes' tumor-suppressive function and drive hamartomatous cell growth. In normal cells, TSC1 and TSC2 integrate growth signals and nutrient inputs to downregulate signaling to mammalian target of rapamycin (mTOR), an evolutionarily conserved serine-threonine kinase that controls cell growth and cell survival. The molecular connection between TSC and mTOR led to the clinical use of allosteric mTOR inhibitors (sirolimus and everolimus) for the treatment of TSC. Everolimus is approved for subependymal giant cell astrocytomas and renal angiomyolipomas in patients with TSC. Sirolimus, though not approved for TSC, has undergone considerable investigation to treat various aspects of the disease. Everolimus and sirolimus selectively inhibit mTOR signaling with similar molecular mechanisms, but with distinct clinical profiles. This review differentiates mTOR inhibitors in TSC while describing the molecular mechanisms, pathogenic mutations, and clinical trial outcomes for managing TSC. PMID:26289591

Clinical Documents: Attribute-Values Entity Representation, Context, Page Layout And Communication

PubMed Central

Lovis, Christian; Lamb, Alexander; Baud, Robert; Rassinoux, Anne-Marie; Fabry, Paul; Geissbühler, Antoine

2003-01-01

This paper presents how acquisition, storage and communication of clinical documents are implemented at the University Hospitals of Geneva. Careful attention has been given to user-interfaces, in order to support complex layouts, spell checking, templates management with automatic prefilling in order to facilitate acquisition. A dual architecture has been developed for storage using an attributes-values entity unified database and a consolidated, patient-centered, layout-respectful files-based storage, providing both representation power and sinsert (peed of accesses. This architecture allows great flexibility to store a continuum of data types from simple type values up to complex clinical reports. Finally, communication is entirely based on HTTP-XML internally and a HL-7 CDA interface V2 is currently studied for external communication. Some of the problem encountered, mostly concerning the typology of documents and the ontology of clinical attributes are evoked. PMID:14728202

Rated casemix of general practitioner referrals to practice counsellors and clinical psychologists: A retrospective survey of a year's caseload.

PubMed

Cape, John; Parham, Alan

2001-06-01

Although evidence-based guidelines are beginning to be produced as to which psychological therapies might be appropriate for which patients, little is known about how general medical practitioners (GPs) in practice distribute referrals between different psychological therapy services. In a retrospective survey, 19 practice counsellors and 10 clinical psychologists from the same geographical area rated a year's caseload of GP referrals using identical data collection methods. Rated casemix was found to be broadly similar, although practice counsellors rated relationship and bereavement problems as more common in their caseloads (totalling 986 patients), and clinical psychologists rated panic disorder, phobias, and obsessive-compulsive problems as more common in their caseloads (totalling 320 patients). Depression and anxiety reactions were the most common problems rated in both groups, but the clinical psychologist cases of depression were rated as more severe and complex. Where differences were found, they may have reflected the different ways that counsellors and clinical psychologists conceptualize cases rather than actual differences in casemix. The results are discussed in relation to evidence-based guideline recommendations about cases appropriate to be seen by practice counsellors and by clinical psychologists in primary and secondary care, and the need to adapt such guidance to local services and skills of practitioners.

Rated casemix of general practitioner referrals to practice counsellors and clinical psychologists: a retrospective survey of a year's caseload.

PubMed

Cape, J; Parham, A

2001-06-01

Although evidence-based guidelines are beginning to be produced as to which psychological therapies might be appropriate for which patients, little is known about how general medical practitioners (GPs) in practice distribute referrals between different psychological therapy services. In a retrospective survey, 19 practice counsellors and 10 clinical psychologists from the same geographical area rated a year's caseload of GP referrals using identical data collection methods. Rated casemix was found to be broadly similar, although practice counsellors rated relationship and bereavement problems as more common in their caseloads (totalling 986 patients), and clinical psychologists rated panic disorder, phobias, and obsessive-compulsive problems as more common in their caseloads (totalling 320 patients). Depression and anxiety reactions were the most common problems rated in both groups, but the clinical psychologist cases of depression were rated as more severe and complex. Where differences were found, they may have reflected the different ways that counsellors and clinical psychologists conceptualize cases rather than actual differences in casemix. The results are discussed in relation to evidence-based guideline recommendations about cases appropriate to be seen by practice counsellors and by clinical psychologists in primary and secondary care, and the need to adapt such guidance to local services and skills of practitioners.

Mixture-based gatekeeping procedures in adaptive clinical trials.

PubMed

Kordzakhia, George; Dmitrienko, Alex; Ishida, Eiji

2018-01-01

Clinical trials with data-driven decision rules often pursue multiple clinical objectives such as the evaluation of several endpoints or several doses of an experimental treatment. These complex analysis strategies give rise to "multivariate" multiplicity problems with several components or sources of multiplicity. A general framework for defining gatekeeping procedures in clinical trials with adaptive multistage designs is proposed in this paper. The mixture method is applied to build a gatekeeping procedure at each stage and inferences at each decision point (interim or final analysis) are performed using the combination function approach. An advantage of utilizing the mixture method is that it enables powerful gatekeeping procedures applicable to a broad class of settings with complex logical relationships among the hypotheses of interest. Further, the combination function approach supports flexible data-driven decisions such as a decision to increase the sample size or remove a treatment arm. The paper concludes with a clinical trial example that illustrates the methodology by applying it to develop an adaptive two-stage design with a mixture-based gatekeeping procedure.

Adjuvant chemotherapy decisions in clinical practice for early-stage node-negative, estrogen receptor-positive, HER2-negative breast cancer: challenges and considerations.

PubMed

Nagaraj, Gayathri; Ma, Cynthia X

2013-03-01

Decisions regarding adjuvant chemotherapy for patients with estrogen receptor (ER)-positive, HER2-negative, lymph node-negative breast cancer have traditionally relied on clinical and pathologic parameters. However, the molecular heterogeneity and the complex tumor genome demand more sophisticated approaches to the problem. Several multigene-based assays have been developed to better prognosticate the risk of recurrence and death and predict benefit of therapy in this patient population. Oncologists are often faced with the challenge of incorporating these various complex genome-based biomarkers along with the traditional biomarkers in clinical decision-making. The NCCN Clinical Practice Guidelines in Oncology for Breast Cancer are helpful in providing a general recommendation. However, uncertainty remains in the absence of definitive data for various clinical scenarios. This case report describes a postmenopausal woman with stage I breast cancer that is low-grade and ER-rich, and has an intermediate Oncotype DX recurrence score of 28.

When trust is threatened: Qualitative study of parents' perspectives on problematic clinical relationships in child cancer care.

PubMed

Davies, Sarah; Salmon, Peter; Young, Bridget

2017-09-01

We explored parents' accounts of the parent-clinician relationship in childhood cancer to understand how parents who perceive threats to the relationship can be supported. Multicentre longitudinal qualitative study, with 67 UK parents of children (aged 1-12 years) receiving treatment for acute lymphoblastic leukaemia. Analyses drew on the wider sample but focussed on 50 semistructured interviews with 20 parents and were informed by constant comparison. All 20 parents described problems with clinical care such as inadequate information or mistakes by staff but varied in how much the problems threatened their sense of relationship with clinicians. Some parents saw the problems as having no relevance to the parent-clinician relationship. Others saw the problems as threats to the clinical relationship but worked to "contain" the threat in ways that preserved a trusting relationship with at least one senior clinician. Parents' containment work protected the security they needed from the parent-clinician relationship, but containment was a tenuous process for some. A few parents were unable to contain the problems at all; lacking trust in clinicians, these parents suffered considerably. Given the complexity of childhood cancer care, problems with clinical care are inevitable. By engaging in containment work, parents met their needs to feel secure in the face of these problems, but the extent to which parents should have to do this work is debatable. Parents could benefit from support to seek help when problems arise which threaten their trust in clinicians. Attachment theory can guide clinicians in giving this support. © 2017 The Authors. Psycho-Oncology Published by John Wiley & Sons Ltd.

Managing common marital stresses.

PubMed

Martin, A C; Starling, B P

1989-10-01

Marital conflict and divorce are problems of great magnitude in our society, and nurse practitioners are frequently asked by patients to address marital problems in clinical practice. "Family life cycle theory" provides a framework for understanding the common stresses of marital life and for developing nursing strategies to improve marital satisfaction. If unaddressed, marital difficulties have serious adverse consequences for a couple's health, leading to greater dysfunction and a decline in overall wellness. This article focuses on identifying couples in crisis, assisting them to achieve pre-crisis equilibrium or an even higher level of functioning, and providing appropriate referral if complex relationship problems exist.

Another level of leadership: nurses on boards.

PubMed

Bleich, Michael R

2014-12-01

The movement to place nurses on boards of directors is growing, enriching boards with individuals possessing knowledge of clinical quality tied to care delivery models, human resource competencies and management, finance, and organizational change. Professional development educators are poised to advance a board's capacity to address complex health care problems.

Clinical Assessment of Dissociative Identity Disorder among College Counseling Clients

ERIC Educational Resources Information Center

Levy, Benjamin; Swanson, Janine E.

2008-01-01

College counseling professionals address a wide range of complex student mental health concerns. Among these, accurately identifying client presentations of dissociative identity disorder (DID) can be especially challenging because students with DID sometimes present as if they are experiencing another problem, such as a mood, anxiety, or…

Sub-Lexical Reading Intervention in a Student with Dyslexia and Asperger's Disorder

ERIC Educational Resources Information Center

Wright, Craig; Conlon, Elizabeth; Wright, Michalle; Dyck, Murray

2011-01-01

Dyslexia is a common presenting condition in clinic and educational settings. Unlike the homogenous groups used in randomised trials, educators typically manage children who have multiple developmental problems. Investigations are required into how these complex cases respond to treatment identified as efficacious by controlled trials. This study…

Decision-Making and Problem-Solving Approaches in Pharmacy Education

PubMed Central

Martin, Lindsay C.; Holdford, David A.

2016-01-01

Domain 3 of the Center for the Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes recommends that pharmacy school curricula prepare students to be better problem solvers, but are silent on the type of problems they should be prepared to solve. We identified five basic approaches to problem solving in the curriculum at a pharmacy school: clinical, ethical, managerial, economic, and legal. These approaches were compared to determine a generic process that could be applied to all pharmacy decisions. Although there were similarities in the approaches, generic problem solving processes may not work for all problems. Successful problem solving requires identification of the problems faced and application of the right approach to the situation. We also advocate that the CAPE Outcomes make explicit the importance of different approaches to problem solving. Future pharmacists will need multiple approaches to problem solving to adapt to the complexity of health care. PMID:27170823

Decision-Making and Problem-Solving Approaches in Pharmacy Education.

PubMed

Martin, Lindsay C; Donohoe, Krista L; Holdford, David A

2016-04-25

Domain 3 of the Center for the Advancement of Pharmacy Education (CAPE) 2013 Educational Outcomes recommends that pharmacy school curricula prepare students to be better problem solvers, but are silent on the type of problems they should be prepared to solve. We identified five basic approaches to problem solving in the curriculum at a pharmacy school: clinical, ethical, managerial, economic, and legal. These approaches were compared to determine a generic process that could be applied to all pharmacy decisions. Although there were similarities in the approaches, generic problem solving processes may not work for all problems. Successful problem solving requires identification of the problems faced and application of the right approach to the situation. We also advocate that the CAPE Outcomes make explicit the importance of different approaches to problem solving. Future pharmacists will need multiple approaches to problem solving to adapt to the complexity of health care.

Novel examination for evaluating medical student clinical reasoning: reliability and association with patients seen.

PubMed

Hemmer, Paul A; Dong, Ting; Durning, Steven J; Pangaro, Louis N

2015-04-01

Medical students learn clinical reasoning, in part, through patient care. Although the numbers of patients seen is associated with knowledge examination scores, studies have not demonstrated an association between patient problems and an assessment of clinical reasoning. To examine the reliability of a clinical reasoning examination and investigate whether there was association between internal medicine core clerkship students' performance on this examination and the number of patients they saw with matching problems during their internal medicine clerkship. Students on the core internal medicine clerkship at the Uniformed Services University students log 11 core patient problems based on the Clerkship Directors in Internal Medicine curriculum. On a final clerkship examination (Multistep), students watch a scripted video encounter between physician and patient actors that assesses three sequential steps in clinical reasoning: Step One focuses on history and physical examination; Step Two, students write a problem list after viewing additional clinical findings; Step Three, students complete a prioritized differential diagnosis and treatment plan. Each Multistep examination has three different cases. For graduating classes 2010-2012 (n = 497), we matched the number of patients seen with the problem most represented by the Multistep cases (epigastric pain, generalized edema, monoarticular arthritis, angina, syncope, pleuritic chest pain). We report two-way Pearson correlations between the number of patients students reported with similar problems and the student's percent score on: Step One, Step Two, Step Three, and Overall Test. Multistep reliability: Step 1, 0.6 to 0.8; Step 2, 0.41 to 0.65; Step 3, 0.53 to 0.78; Overall examination (3 cases): 0.74 to 0.83. For three problems, the number of patients seen had small to modest correlations with the Multistep Examination of Analytic Ability total score (r = 0.27 for pleuritic pain, p < 0.05, n = 81 patients; r = 0.14 for epigastric pain, p < 0.05, n = 324 patients; r = 0.19 for generalized edema, p < 0.05, n = 118 patients). DISCUSSION or Although a reliable assessment, student performance on a clinical reasoning examination was weakly associated with the numbers of patients seen with similar problems. This may be as a result of transfer of knowledge between clinical and examination settings, the complexity of clinical reasoning, or the limits of reliability with patient logs and the Multistep. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Clinician burnout and satisfaction with resources in caring for complex patients.

PubMed

Whitebird, Robin R; Solberg, Leif I; Crain, A Lauren; Rossom, Rebecca C; Beck, Arne; Neely, Claire; Dreskin, Mark; Coleman, Karen J

To describe primary care clinicians' self-reported satisfaction, burnout and barriers for treating complex patients. We conducted a survey of 1554 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states prior to the implementation of a collaborative model of care for patients with depression and diabetes and/or cardiovascular disease. Of the clinicians who responded to the survey (n=709; 46%), we found that a substantial minority (31%) were experiencing burnout that was associated with lower career satisfaction (P<.0001) and lower satisfaction with resources to treat complex patients (P<.0001). Less than 50% of clinicians rated their ability to treat complex patients as very good to excellent with 21% rating their ability as fair to poor. The majority of clinicians (72%) thought that a collaborative model of care would be very helpful for treating complex patients. Burnout remains a problem for primary care clinicians and is associated with low job satisfaction and low satisfaction with resources to treat complex patients. A collaborative care model for patients with mental and physical health problems may provide the resources needed to improve the quality of care for these patients. Copyright © 2016 Elsevier Inc. All rights reserved.

A New Classification of Endodontic-Periodontal Lesions

PubMed Central

Al-Fouzan, Khalid S.

2014-01-01

The interrelationship between periodontal and endodontic disease has always aroused confusion, queries, and controversy. Differentiating between a periodontal and an endodontic problem can be difficult. A symptomatic tooth may have pain of periodontal and/or pulpal origin. The nature of that pain is often the first clue in determining the etiology of such a problem. Radiographic and clinical evaluation can help clarify the nature of the problem. In some cases, the influence of pulpal pathology may cause the periodontal involvement and vice versa. The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning. An endo-perio lesion can have a varied pathogenesis which ranges from simple to relatively complex one. The differential diagnosis of endodontic and periodontal diseases can sometimes be difficult, but it is of vital importance to make a correct diagnosis for providing the appropriate treatment. This paper aims to discuss a modified clinical classification to be considered for accurately diagnosing and treating endo-perio lesion. PMID:24829580

A new classification of endodontic-periodontal lesions.

PubMed

Al-Fouzan, Khalid S

2014-01-01

The interrelationship between periodontal and endodontic disease has always aroused confusion, queries, and controversy. Differentiating between a periodontal and an endodontic problem can be difficult. A symptomatic tooth may have pain of periodontal and/or pulpal origin. The nature of that pain is often the first clue in determining the etiology of such a problem. Radiographic and clinical evaluation can help clarify the nature of the problem. In some cases, the influence of pulpal pathology may cause the periodontal involvement and vice versa. The simultaneous existence of pulpal problems and inflammatory periodontal disease can complicate diagnosis and treatment planning. An endo-perio lesion can have a varied pathogenesis which ranges from simple to relatively complex one. The differential diagnosis of endodontic and periodontal diseases can sometimes be difficult, but it is of vital importance to make a correct diagnosis for providing the appropriate treatment. This paper aims to discuss a modified clinical classification to be considered for accurately diagnosing and treating endo-perio lesion.

[Thought on several problems of clinical revaluation of post-marketing herb research].

PubMed

He, Wei; Xie, Yanming; Wang, Yongyan

2010-06-01

The revaluation of post-marketing herb is a complex research work, which concerns widely content and difficult to put it into practice. The starting of our country's revaluation post-marketing herb was comparatively late. It should profect it both in laws and regulations mechanism as well as technological specification. This article is try to focus on some attention problems in revaluation of postmarketing herb process. Such as the laws and regulations demand, the basement and the subject of revaluation of post-marketing herb.

Team approach to treatment of the posttraumatic stiff hand. A case report.

PubMed

Morey, K R; Watson, A H

1986-02-01

Posttraumatic hand stiffness is a common but complex problem treated in many general clinics and in hand treatment centers. Although much information is available regarding various treatment procedures, the use of a team approach to evaluate and treat hand stiffness has not been examined thoroughly in the Journal. The problems of the patient with a stiff hand include both physical and psychological components that must be addressed in a structured manner. The clinical picture of posttraumatic hand stiffness involves edema, immobility, pain, and the inability to incorporate the affected extremity into daily activities. In this case report, we review the purpose and philosophy of the team approach to hand therapy and the clarification of responsibilities for physical therapy and occupational therapy intervention.

[Complex treatment of tobacco dependence by means of psychotherapeutic correction in combination with mesodiencephalic modulation in patients with chronic diseases of digestive organs].

PubMed

Rassulova, M A; Safonova, O V; Ksenofontova, I V; Firsova, L D

2010-01-01

This paper deals with the problem of tobacco dependence and its medical treatment. Various methods available for this purpose are considered with special reference to their clinical efficiency. A scheme for combined treatment of the given pathology is proposed.

Broadening Professional Education on the Margins and between the Niches.

ERIC Educational Resources Information Center

Krieger, Martin H.

1990-01-01

A promising model for professional education is the workshop, studio, or clinic, wherein a team takes on the complexity of actual situations and must figure out what to do. In these situations, individual abstracted problem solving is secondary. In general education, instructors and students are less protected by disciplinary fences. (MLW)

Using Reliable Change to Calculate Clinically Significant Progress in Children with EBD: A BHRS Program Evaluation

ERIC Educational Resources Information Center

Thoder, Vincent J.; Hesky, James G.; Cautilli, Joseph D.

2010-01-01

Children often have complex emotional and behavioral disorders (ADHD, ODD, Depression, PTSD, etc.). A large amount of research exists in the behavioral treatment of children with these disorders regarding specific behavioral problems. Much less research exists for the treatment of comprehensive problematic behaviors that these children experience…

Chronic Hepatitis C Infection in a Rural Medicaid HMO

ERIC Educational Resources Information Center

Calvert Jr., James F.; Goldenberg, Paula C.; Schock, Cathy

2005-01-01

Chronic hepatitis C infection (CHCI) is an increasingly common problem, affecting about 2% of the US population. The cost and complexity of treatment and difficulties in communicating with the infected population are of concern to insurers and health planners. Purpose: To describe the clinical features of patients with CHCI in a rural…

Implementing Problem Based Learning through Engineers without Borders Student Projects

ERIC Educational Resources Information Center

Wittig, Ann

2013-01-01

Engineers Without Borders USA (EWB) is a nonprofit organization that partners student chapters with communities in fundamental need of potable water, clean air, sanitation, irrigation, energy, basic structures for schools and clinics, roads and bridges, etc. While EWB projects may vary in complexity, they are all realistic, ill-structured and…

[Errors in wound management].

PubMed

Filipović, Marinko; Novinscak, Tomislav

2014-10-01

Chronic ulcers have adverse effects on the patient quality of life and productivity, thus posing financial burden upon the healthcare system. Chronic wound healing is a complex process resulting from the interaction of the patient general health status, wound related factors, medical personnel skill and competence, and therapy related products. In clinical practice, considerable improvement has been made in the treatment of chronic wounds, which is evident in the reduced rate of the severe forms of chronic wounds in outpatient clinics. However, in spite of all the modern approaches, efforts invested by medical personnel and agents available for wound care, numerous problems are still encountered in daily practice. Most frequently, the problems arise from inappropriate education, of young personnel in particular, absence of multidisciplinary approach, and inadequate communication among the personnel directly involved in wound treatment. To perceive them more clearly, the potential problems or complications in the management of chronic wounds can be classified into the following groups: problems mostly related to the use of wound coverage and other etiology related specificities of wound treatment; problems related to incompatibility of the agents used in wound treatment; and problems arising from failure to ensure aseptic and antiseptic performance conditions.

Students' perceptions of clinical teaching and learning strategies: a Pakistani perspective.

PubMed

Khan, Basnama Ayaz; Ali, Fauziya; Vazir, Nilofar; Barolia, Rubina; Rehan, Seema

2012-01-01

The complexity of the health care environment is increasing with the explosion of technology, coupled with the issues of patients' access, equity, time efficiency, and cost containment. Nursing education must focus on means that enable students to develop the processes of active learning, problem-solving, and critical thinking, in order to enable them to deal with the complexities. This study aims at identifying the nursing students' perceptions about the effectiveness of utilized teaching and learning strategies of clinical education, in improving students' knowledge, skills, and attitudes. A descriptive cross sectional study design was utilized using both qualitative and quantitative approaches. Data were collected from 74 students, using a questionnaire that was developed for the purpose of the study and analyzed using descriptive and non-parametric statistics. The findings revealed that demonstration was the most effective strategy for improving students' skills; reflection, for improving attitudes; and problem based learning and concept map for improving their knowledge. Students' responses to open-ended questions confirmed the effectiveness of these strategies in improving their learning outcomes. Recommendations have been provided based on the findings. Copyright © 2011 Elsevier Ltd. All rights reserved.

Professional boundaries in the era of the Internet.

PubMed

Gabbard, Glen O; Kassaw, Kristin A; Perez-Garcia, Gonzalo

2011-01-01

The era of the Internet presents new dilemmas in educating psychiatrists about professional boundaries. The objective of this overview is to clarify those dilemmas and offer recommendations for dealing with them. The characteristics of social networking sites, blogs, and search engines are reviewed with a specific focus on their potential to present problems of professional boundaries for psychiatrists. The professional boundary questions that have arisen in the expanded world of online communication can be subdivided into three areas: ethical concerns, professionalism issues, and clinical dilemmas. Only the first category involves true boundary problems as normally defined. The expansion of the Internet has redefined traditional areas of privacy and anonymity in the clinical setting. Guidelines are proposed to manage the alteration of professional boundaries, as well as issues of professionalism and clinical work, that have arisen from the complexities of cyberspace. The author discusses implications for residency training.

Advantages of video trigger in problem-based learning.

PubMed

Chan, Lap Ki; Patil, Nivritti G; Chen, Julie Y; Lam, Jamie C M; Lau, Chak S; Ip, Mary S M

2010-01-01

Traditionally, paper cases are used as 'triggers' to stimulate learning in problem-based learning (PBL). However, video may be a better medium because it preserves the original language, encourages the active extraction of information, avoids depersonalization of patients and allows direct observation of clinical consultations. In short, it exposes the students to the complexity of actual clinical problems. The study aims to find out whether students and facilitators who are accustomed to paper cases would prefer video triggers or paper cases and the reasons for their preference. After students and facilitators had completed a video PBL tutorial, their responses were measured by a structured questionnaire using a modified Likert scale. A total of 257 students (92%) and 26 facilitators (100%) responded. The majority of students and facilitators considered that using video triggers could enhance the students' observational powers and clinical reasoning, help them to integrate different information and better understand the cases and motivate them to learn. They found PBL using video triggers more interesting and preferred it to PBL using paper cases. Video triggers are preferred by both students and facilitators over paper cases in PBL.

The complexities of malaria disease manifestations with a focus on asymptomatic malaria

PubMed Central

2012-01-01

Malaria is a serious parasitic disease in the developing world, causing high morbidity and mortality. The pathogenesis of malaria is complex, and the clinical presentation of disease ranges from severe and complicated, to mild and uncomplicated, to asymptomatic malaria. Despite a wealth of studies on the clinical severity of disease, asymptomatic malaria infections are still poorly understood. Asymptomatic malaria remains a challenge for malaria control programs as it significantly influences transmission dynamics. A thorough understanding of the interaction between hosts and parasites in the development of different clinical outcomes is required. In this review, the problems and obstacles to the study and control of asymptomatic malaria are discussed. The human and parasite factors associated with differential clinical outcomes are described and the management and treatment strategies for the control of the disease are outlined. Further, the crucial gaps in the knowledge of asymptomatic malaria that should be the focus of future research towards development of more effective malaria control strategies are highlighted. PMID:22289302

Toward Implementing Patient Flow in a Cancer Treatment Center to Reduce Patient Waiting Time and Improve Efficiency.

PubMed

Suss, Samuel; Bhuiyan, Nadia; Demirli, Kudret; Batist, Gerald

2017-06-01

Outpatient cancer treatment centers can be considered as complex systems in which several types of medical professionals and administrative staff must coordinate their work to achieve the overall goals of providing quality patient care within budgetary constraints. In this article, we use analytical methods that have been successfully employed for other complex systems to show how a clinic can simultaneously reduce patient waiting times and non-value added staff work in a process that has a series of steps, more than one of which involves a scarce resource. The article describes the system model and the key elements in the operation that lead to staff rework and patient queuing. We propose solutions to the problems and provide a framework to evaluate clinic performance. At the time of this report, the proposals are in the process of implementation at a cancer treatment clinic in a major metropolitan hospital in Montreal, Canada.

Using mediation techniques to manage conflict and create healthy work environments.

PubMed

Gerardi, Debra

2004-01-01

Healthcare organizations must find ways for managing conflict and developing effective working relationships to create healthy work environments. The effects of unresolved conflict on clinical outcomes, staff retention, and the financial health of the organization lead to many unnecessary costs that divert resources from clinical care. The complexity of delivering critical care services makes conflict resolution difficult. Developing collaborative working relationships helps to manage conflict in complex environments. Working relationships are based on the ability to deal with differences. Dealing with differences requires skill development and techniques for balancing interests and communicating effectively. Techniques used by mediators are effective for resolving disputes and developing working relationships. With practice, these techniques are easily transferable to the clinical setting. Listening for understanding, reframing, elevating the definition of the problem, and forming clear agreements can foster working relationships, decrease the level of conflict, and create healthy work environments that benefit patients and professionals.

Five heads are better than one: preliminary results of team-based learning in a communication disorders graduate course.

PubMed

Epstein, Baila

2016-01-01

Clinical problem-solving is fundamental to the role of the speech-language pathologist in both the diagnostic and treatment processes. The problem-solving often involves collaboration with clients and their families, supervisors, and other professionals. Considering the importance of cooperative problem-solving in the profession, graduate education in speech-language pathology should provide experiences to foster the development of these skills. One evidence-based pedagogical approach that directly targets these abilities is team-based learning (TBL). TBL is a small-group instructional method that focuses on students' in-class application of conceptual knowledge in solving complex problems that they will likely encounter in their future clinical careers. The purpose of this pilot study was to investigate the educational outcomes and students' perceptions of TBL in a communication disorders graduate course on speech and language-based learning disabilities. Nineteen graduate students (mean age = 26 years, SD = 4.93), divided into three groups of five students and one group of four students, who were enrolled in a required graduate course, participated by fulfilling the key components of TBL: individual student preparation; individual and team readiness assurance tests (iRATs and tRATs) that assessed preparedness to apply course content; and application activities that challenged teams to solve complex and authentic clinical problems using course material. Performance on the tRATs was significantly higher than the individual students' scores on the iRATs (p < .001, Cohen's d = 4.08). Students generally reported favourable perceptions of TBL on an end-of-semester questionnaire. Qualitative analysis of responses to open-ended questions organized thematically indicated students' high satisfaction with application activities, discontent with the RATs, and recommendations for increased lecture in the TBL process. The outcomes of this pilot study suggest the effectiveness of TBL as an instructional method that provides student teams with opportunities to apply course content in problem-solving activities followed by immediate feedback. This research also addresses the dearth of empirical information on how graduate programmes in speech-language pathology bridge students' didactic learning and clinical practice. Future studies should examine the utility of this approach in other courses within the field and with more heterogeneous student populations. © 2015 Royal College of Speech and Language Therapists.

Combining clinical and genomics queries using i2b2 – Three methods

PubMed Central

Murphy, Shawn N.; Avillach, Paul; Bellazzi, Riccardo; Phillips, Lori; Gabetta, Matteo; Eran, Alal; McDuffie, Michael T.; Kohane, Isaac S.

2017-01-01

We are fortunate to be living in an era of twin biomedical data surges: a burgeoning representation of human phenotypes in the medical records of our healthcare systems, and high-throughput sequencing making rapid technological advances. The difficulty representing genomic data and its annotations has almost by itself led to the recognition of a biomedical “Big Data” challenge, and the complexity of healthcare data only compounds the problem to the point that coherent representation of both systems on the same platform seems insuperably difficult. We investigated the capability for complex, integrative genomic and clinical queries to be supported in the Informatics for Integrating Biology and the Bedside (i2b2) translational software package. Three different data integration approaches were developed: The first is based on Sequence Ontology, the second is based on the tranSMART engine, and the third on CouchDB. These novel methods for representing and querying complex genomic and clinical data on the i2b2 platform are available today for advancing precision medicine. PMID:28388645

Presentation and management of chronic pain.

PubMed

Rajapakse, Dilini; Liossi, Christina; Howard, Richard F

2014-05-01

Chronic pain is an important clinical problem affecting significant numbers of children and their families. The severity and impact of chronic pain on everyday function is shaped by the complex interaction of biological, psychological and social factors that determine the experience of pain for each individual, rather than a straightforward reflection of the severity of disease or extent of tissue damage. In this article we present the research findings that strongly support a biopsychosocial concept of chronic pain, describe the current best evidence for management strategies and suggest a common general pathway for all types of chronic pain. The principles of management of some of the most important or frequently encountered chronic pain problems in paediatric practice; neuropathic pain, complex regional pain syndrome (CRPS), musculoskeletal pain, abdominal pain and headache are also described.

Kaizen practice in healthcare: a qualitative analysis of hospital employees' suggestions for improvement.

PubMed

Mazzocato, Pamela; Stenfors-Hayes, Terese; von Thiele Schwarz, Ulrica; Hasson, Henna; Nyström, Monica Elisabeth

2016-07-29

Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this study is to describe the types of issues and improvement suggestions that hospital employees feel empowered to address through kaizen practices in order to understand when and how kaizen is used in healthcare. We analysed 186 structured kaizen documents containing improvement suggestions that were produced by 165 employees at a Swedish hospital. Directed content analysis was used to categorise the suggestions into following categories: type of situation (proactive or reactive) triggering an action; type of process addressed (technical/administrative, support and clinical); complexity level (simple or complex); and type of outcomes aimed for (operational or sociotechnical). Compliance to the kaizen template was calculated. 72% of the improvement suggestions were reactions to a perceived problem. Support, technical and administrative, and primary clinical processes were involved in 47%, 38% and 16% of the suggestions, respectively. The majority of the kaizen documents addressed simple situations and focused on operational outcomes. The degree of compliance to the kaizen template was high for several items concerning the identification of problems and the proposed solutions, and low for items related to the test and implementation of solutions. There is a need to combine kaizen practices with improvement and innovation practices that help staff and managers to address complex issues, such as the improvement of clinical care processes. The limited focus on sociotechnical aspects and the partial compliance to kaizen templates may indicate a limited understanding of the entire kaizen process and of how it relates to the overall organisational goals. This in turn can hamper the sustainability of kaizen practices and results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle.

PubMed

Tarrant, Carolyn; O'Donnell, Barbara; Martin, Graham; Bion, Julian; Hunter, Alison; Rooney, Kevin D

2016-11-16

Implementation of the 'Sepsis Six' clinical care bundle within an hour of recognition of sepsis is recommended as an approach to reduce mortality in patients with sepsis, but achieving reliable delivery of the bundle has proved challenging. There remains little understanding of the barriers to reliable implementation of bundle components. We examined frontline clinical practice in implementing the Sepsis Six. We conducted an ethnographic study in six hospitals participating in the Scottish Patient Safety Programme Sepsis collaborative. We conducted around 300 h of non-participant observation in emergency departments, acute medical receiving units and medical and surgical wards. We interviewed a purposive sample of 43 members of hospital staff. Data were analysed using a constant comparative approach. Implementation strategies to promote reliable use of the Sepsis Six primarily focused on education, engaging and motivating staff, and providing prompts for behaviour, along with efforts to ensure that equipment required was readily available. Although these strategies were successful in raising staff awareness of sepsis and engagement with implementation, our study identified that completing the bundle within an hour was not straightforward. Our emergent theory suggested that rather than being an apparently simple sequence of six steps, the Sepsis Six actually involved a complex trajectory comprising multiple interdependent tasks that required prioritisation and scheduling, and which was prone to problems of coordination and operational failures. Interventions that involved allocating specific roles and responsibilities for completing the Sepsis Six in ways that reduced the need for coordination and task switching, and the use of process mapping to identify system failures along the trajectory, could help mitigate against some of these problems. Implementation efforts that focus on individual behaviour change to improve uptake of the Sepsis Six should be supplemented by an understanding of the bundle as a complex trajectory of work in which improving reliability requires attention to coordination of workflow, as well as addressing the mundane problems of interruptions and operational failures that obstruct task completion.

The presentation and management of complex female genital malformations.

PubMed

Acién, Pedro; Acién, Maribel

2016-01-01

Common uterine anomalies are important owing to their impact on fertility, and complex mesonephric anomalies and certain Müllerian malformations are particularly important because they cause serious clinical symptoms and affect woman's quality of life, in addition to creating fertility problems. In these cases of complex female genital tract malformations, a correct diagnosis is essential to avoid inappropriate and/or unnecessary surgery. Therefore, acquiring and applying the appropriate embryological knowledge, management and therapy is a challenge for gynaecologists. Here, we considered complex malformations to be obstructive anomalies and/or those associated with cloacal and urogenital sinus anomalies, urinary and/or extragenital anomalies, or other clinical implications or symptoms creating a difficult differential diagnosis. A diligent and comprehensive search of PubMed and Scopus was performed for all studies published from 1 January 2011 to 15 April 2015 (then updated up to September 2015) using the following search terms: 'management' in combination with either 'female genital malformations' or 'female genital tract anomalies' or 'Müllerian anomalies'. The MeSH terms 'renal agenesis', 'hydrocolpos', 'obstructed hemivagina' 'cervicovaginal agenesis or atresia', 'vaginal agenesis or atresia', 'Herlyn-Werner-Wunderlich syndrome', 'uterine duplication' and 'cloacal anomalies' were also used to compile a list of all publications containing these terms since 2011. The basic embryological considerations for understanding female genitourinary malformations were also revealed. Based on our experience and the updated literature review, we studied the definition and classification of the complex malformations, and we analysed the clinical presentation and different therapeutic strategies for each anomaly, including the embryological and clinical classification of female genitourinary malformations. From 755 search retrieved references, 230 articles were analysed and 120 studied in detail. They were added to those included in a previous systematic review. Here, we report the clinical presentation and management of: agenesis or hypoplasia of one urogenital ridge; unilateral renal agenesis and ipsilateral blind or obstructed hemivagina or unilateral cervicovaginal agenesis; cavitated and non-communicating uterine horns and Müllerian atresias or agenesis, including Rokitansky syndrome; anomalies of the cloaca and urogenital sinus, including congenital vagino-vesical fistulas and cloacal anomalies; malformative combinations and other complex malformations. The clinical symptoms and therapeutic strategies for each complex genitourinary malformation are discussed. In general, surgical techniques to correct genital malformations depend on the type of anomaly, its complexity, the patient's symptoms and the correct embryological interpretation of the anomaly. Most anomalies can typically be resolved vaginally or by hysteroscopy, but laparoscopy or laparotomy is often required as well. We also include additional discussion of the catalogue and classification systems for female genital malformations, the systematic association between renal agenesis and ipsilateral genital malformation, and accessory and cavitated uterine masses. Knowledge of the correct genitourinary embryology is essential for the understanding, study, diagnosis and subsequent treatment of genital malformations, especially complex ones and those that lead to gynaecological and reproductive problems, particularly in young patients. Some anomalies may require complex surgery involving multiple specialties, and patients should therefore be referred to centres that have experience in treating complex genital malformations. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Describing the content of primary care: limitations of Canadian billing data.

PubMed

Katz, Alan; Halas, Gayle; Dillon, Michael; Sloshower, Jordan

2012-02-15

Primary health care systems are designed to provide comprehensive patient care. However, the ICD 9 coding system used for billing purposes in Canada neither characterizes nor captures the scope of clinical practice or complexity of physician-patient interactions. This study aims to describe the content of primary care clinical encounters and examine the limitations of using administrative data to capture the content of these visits. Although a number of U.S studies have described the content of primary care encounters, this is the first Canadian study to do so. Study-specific data collection forms were completed by 16 primary care physicians in community health and family practice clinics in Winnipeg, Manitoba, Canada. The data collection forms were completed immediately following the patient encounter and included patient and visit characteristics, such as primary reason for visit, topics discussed, actions taken, degree of complexity as well as diagnosis and ICD-9 codes. Data was collected for 760 patient encounters. The diagnostic codes often did not reflect the dominant topic of the visit or the topic requiring the most amount of time. Physicians often address multiple problems and provide numerous services thus increasing the complexity of care. This is one of the first Canadian studies to critically analyze the content of primary care clinical encounters. The data allowed a greater understanding of primary care clinical encounters and attests to the deficiencies of singular ICD-9 coding which fails to capture the comprehensiveness and complexity of the primary care encounter. As primary care reform initiatives in the U.S and Canada attempt to transform the way family physicians deliver care, it becomes increasingly important that other tools for structuring primary care data are considered in order to help physicians, researchers and policy makers understand the breadth and complexity of primary care.

Computer-based training for improving mental calculation in third- and fifth-graders.

PubMed

Caviola, Sara; Gerotto, Giulia; Mammarella, Irene C

2016-11-01

The literature on intervention programs to improve arithmetical abilities is fragmentary and few studies have examined training on the symbolic representation of numbers (i.e. Arabic digits). In the present research, three groups of 3rd- and 5th-grade schoolchildren were given training on mental additions: 76 were assigned to a computer-based strategic training (ST) group, 73 to a process-based training (PBT) group, and 71 to a passive control (PC) group. Before and after the training, the children were given a criterion task involving complex addition problems, a nearest transfer task on complex subtraction problems, two near transfer tasks on math fluency, and a far transfer task on numerical reasoning. Our results showed developmental differences: 3rd-graders benefited more from the ST, with transfer effects on subtraction problems and math fluency, while 5th-graders benefited more from the PBT, improving their response times in the criterion task. Developmental, clinical and educational implications of these findings are discussed. Copyright © 2016 Elsevier B.V. All rights reserved.

Complex trauma and mental health in children and adolescents placed in foster care: findings from the National Child Traumatic Stress Network.

PubMed

Greeson, Johanna K P; Briggs, Ernestine C; Kisiel, Cassandra L; Layne, Christopher M; Ake, George S; Ko, Susan J; Gerrity, Ellen T; Steinberg, Alan M; Howard, Michael L; Pynoos, Robert S; Fairbank, John A

2011-01-01

Many children in the child welfare system (CWS) have histories of recurrent interpersonal trauma perpetrated by caregivers early in life often referred to as complex trauma. Children in the CWS also experience a diverse range of reactions across multiple areas of functioning that are associated with such exposure. Nevertheless, few CWSs routinely screen for trauma exposure and associated symptoms beyond an initial assessment of the precipitating event. This study examines trauma histories, including complex trauma exposure (physical abuse, sexual abuse, emotional abuse, neglect, domestic violence), posttraumatic stress, and behavioral and emotional problems of 2,251 youth (age 0 to 21; M = 9.5, SD = 4.3) in foster care who were referred to a National Child Traumatic Stress Network site for treatment. High prevalence rates of complex trauma exposure were observed: 70.4% of the sample reported at least two of the traumas that constitute complex trauma; 11.7% of the sample reported all 5 types. Compared to youth with other types of trauma, those with complex trauma histories had significantly higher rates of internalizing problems, posttraumatic stress, and clinical diagnoses, and differed on some demographic variables. Implications for child welfare practice and future research are discussed.

Subtypes in 22q11.2 Deletion Syndrome Associated with Behaviour and Neurofacial Morphology

ERIC Educational Resources Information Center

Sinderberry, Brooke; Brown, Scott; Hammond, Peter; Stevens, Angela F.; Schall, Ulrich; Murphy, Declan G. M.; Murphy, Kieran C.; Campbell, Linda E.

2013-01-01

22q11.2 deletion syndrome (22q11DS) has a complex phenotype with more than 180 characteristics, including cardiac anomalies, cleft palate, intellectual disabilities, a typical facial morphology, and mental health problems. However, the variable phenotype makes it difficult to predict clinical outcome, such as the high prevalence of psychosis among…

The Application of Traditional Martial Arts Practice and Theory to the Treatment of Violent Adolescents.

ERIC Educational Resources Information Center

Twemlow, Stuart W.; Sacco, Frank C.

1998-01-01

Reviews treatment programs, the complex problems posed by youth gangs, and the use of martial arts in the treatment of violence and proposes a program for violent adolescents. The program philosophy is committed to respect and self-control; emphasis is on leadership and community service. Provides clinical examples. (Author/EMK)

Empirical and Clinical Methods in the Assessment of Personality and Psychopathology: An Integrative Approach for Training

ERIC Educational Resources Information Center

Flanagan, Rosemary; Esquivel, Giselle B.

2006-01-01

School psychologists have a critical role in identifying social-emotional problems and psychopathology in youth based on a set of personality-assessment competencies. The development of competencies in assessing personality and psychopathology is complex, requiring a variety of integrated methods and approaches. Given the limited extent and scope…

Can Classification Tree Analyses Help Improve Decision Making About Treatments for Depression and Anxiety Disorders? A Preliminary Investigation

PubMed Central

Rhodes, Louisa; Naumann, Ulrike M.

2011-01-01

Objective: To identify how decisions about treatment are being made in secondary services for anxiety disorders and depression and, specifically, whether it was possible to predict the decisions to refer for evidence-based treatments. Method: Post hoc classification tree analysis was performed using a sample from an audit on implementation of the National Institute for Health and Clinical Excellence Guidelines for Depression and Anxiety Disorders. The audit was of 5 teams offering secondary care services; they included psychiatrists, psychologists, community psychiatric nurses, social workers, dual-diagnosis workers, and vocational workers. The patient sample included all of those with a primary problem of depression (n = 56) or an anxiety disorder (n = 16) who were offered treatment from February 16 to April 3, 2009. The outcome variable was whether or not evidence-based treatments were offered, and the predictor variables were presenting problem, risk, comorbid problem, social problems, and previous psychiatric history. Results: Treatment decisions could be more accurately predicted for anxiety disorders (93% correct) than for depression (55%). For anxiety disorders, the presence or absence of social problems was a good predictor for whether evidence-based or non–evidence-based treatments were offered; 44% (4/9) of those with social problems vs 100% (6/6) of those without social problems were offered evidence-based treatments. For depression, patients’ risk rating had the largest impact on treatment decisions, although no one variable could be identified as individually predictive of all treatment decisions. Conclusions: Treatment decisions were generally consistent for anxiety disorders but more idiosyncratic for depression, making the development of a decision-making model very difficult for depression. The lack of clarity of some terms in the clinical guidelines and the more complex nature of depression could be factors contributing to this difficulty. Further research is needed to understand the complex nature of decision making with depressed patients. PMID:22295255

Facial anatomy.

PubMed

Marur, Tania; Tuna, Yakup; Demirci, Selman

2014-01-01

Dermatologic problems of the face affect both function and aesthetics, which are based on complex anatomical features. Treating dermatologic problems while preserving the aesthetics and functions of the face requires knowledge of normal anatomy. When performing successfully invasive procedures of the face, it is essential to understand its underlying topographic anatomy. This chapter presents the anatomy of the facial musculature and neurovascular structures in a systematic way with some clinically important aspects. We describe the attachments of the mimetic and masticatory muscles and emphasize their functions and nerve supply. We highlight clinically relevant facial topographic anatomy by explaining the course and location of the sensory and motor nerves of the face and facial vasculature with their relations. Additionally, this chapter reviews the recent nomenclature of the branching pattern of the facial artery. © 2013 Elsevier Inc. All rights reserved.

Improving the Quality of Home Health Care for Children With Medical Complexity.

PubMed

Nageswaran, Savithri; Golden, Shannon L

2017-08-01

The objectives of this study are to describe the quality of home health care services for children with medical complexity, identify barriers to delivering optimal home health care, and discuss potential solutions to improve home health care delivery. In this qualitative study, we conducted 20 semistructured in-depth interviews with primary caregivers of children with medical complexity, and 4 focus groups with 18 home health nurses. During an iterative analysis process, we identified themes related to quality of home health care. There is substantial variability between home health nurses in the delivery of home health care to children. Lack of skills in nurses is common and has serious negative health consequences for children with medical complexity, including hospitalizations, emergency room visits, and need for medical procedures. Inadequate home health care also contributes to caregiver burden. A major barrier to delivering optimal home health care is the lack of training of home health nurses in pediatric care and technology use. Potential solutions for improving care include home health agencies training nurses in the care of children with medical complexity, support for nurses in clinical problem solving, and reimbursement for training nurses in pediatric home care. Caregiver-level interventions includes preparation of caregivers about: providing medical care for their children at home and addressing problems with home health care services. There are problems in the quality of home health care delivered to children with medical complexity. Training nurses in the care of children with medical complexity and preparing caregivers about home care could improve home health care quality. Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

[Description of the mental processes occurring during clinical reasoning].

PubMed

Pottier, P; Planchon, B

2011-06-01

Clinical reasoning is a highly complex system with multiple inter-dependent mental activities. Gaining a better understanding of those cognitive processes has two practical implications: for physicians, being able to analyse their own reasoning method may prove to be helpful in diagnostic dead end; for medical teachers, identifying problem-solving strategies used by medical students may foster an appropriate individual feed-back aiming at improving their clinical reasoning skills. On the basis of a detailed literature review, the main diagnostic strategies and their related pattern of mental processes are described and illustrated with a concrete example, going from the patient's complaint to the chosen solution. Inductive, abductive and deductive diagnostic approaches are detailed. Different strategies for collecting data (exhaustive or oriented) and for problem-building are described. The place of problem solving strategies such as pattern-recognition, scheme inductive process, using of clinical script, syndrome grouping and mental hypotheses test is considered. This work aims at breaking up mental activities in process within clinical reasoning reminding that expert reasoning is characterised by the ability to use and structure the whole of these activities in a coherent system, using combined strategies in order to guarantee a better accuracy of their diagnosis. Copyright © 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.

Multiple clinical presentations of anal ultra slow waves and high anal pressure: megacolon, hemorrhoids and constipation.

PubMed

Yoshino, Hiroaki; Kayaba, Hiroyuki; Hebiguchi, Tatsuzo; Morii, Mayako; Hebiguchi, Taku; Ito, Wataru; Chihara, Junichi; Kato, Tetsuo

2007-02-01

The physiopathology of idiopathic chronic constipation is complex and yet to be investigated. In the manometric studies of the patients with severe chronic constipation, we noticed that some patients with megacolon show very slow periodical (< 2/min) pressure change in the anal canal, namely ultra slow waves (USWs). USWs are considered to represent the hyperactivity of the internal anal sphincter; however, USW-related clinical presentations have yet to be investigated. We retrospectively re-evaluated the patient records and manometric studies of 85 cases, 51 subjects without defecatory problems and 34 patients with constipation, to elucidate USW-related clinical presentations. USWs were seen in 10 patients, including eight patients with chronic constipation and two subjects without defecatory problems. Out of the eight patients with constipation, one had no organic change in the anorectum, three had hemorrhoids and four exhibited megacolon. Manometric and pathological studies proved that none of the four patients with megacolon was suffering from Hirschsprung's disease. Among the 51 subjects without defecatory problems, only two had USWs. Anal pressure in the USW-positive group (106.0 +/- 37.0 cmH2O) was significantly higher than that in the group without defecatory problems (56.0 +/- 27.0 cmH2O) or constipated patients without USWs (55.0 +/- 26.0 cmH2O). Megacolon and high anal pressure, as well as chronic constipation and hemorrhoids, were the clinical presentations related to USWs. This is the first report to show the clinical relevance of USWs to megacolon. USWs should be recognized as an important manometric finding indicating a possible new clinical entity in chronic constipation.

A model for integrating clinical care and basic science research, and pitfalls of performing complex research projects for addressing a clinical challenge.

PubMed

Steck, R; Epari, D R; Schuetz, M A

2010-07-01

The collaboration of clinicians with basic science researchers is crucial for addressing clinically relevant research questions. In order to initiate such mutually beneficial relationships, we propose a model where early career clinicians spend a designated time embedded in established basic science research groups, in order to pursue a postgraduate qualification. During this time, clinicians become integral members of the research team, fostering long term relationships and opening up opportunities for continuing collaboration. However, for these collaborations to be successful there are pitfalls to be avoided. Limited time and funding can lead to attempts to answer clinical challenges with highly complex research projects characterised by a large number of "clinical" factors being introduced in the hope that the research outcomes will be more clinically relevant. As a result, the complexity of such studies and variability of its outcomes may lead to difficulties in drawing scientifically justified and clinically useful conclusions. Consequently, we stress that it is the basic science researcher and the clinician's obligation to be mindful of the limitations and challenges of such multi-factorial research projects. A systematic step-by-step approach to address clinical research questions with limited, but highly targeted and well defined research projects provides the solid foundation which may lead to the development of a longer term research program for addressing more challenging clinical problems. Ultimately, we believe that it is such models, encouraging the vital collaboration between clinicians and researchers for the work on targeted, well defined research projects, which will result in answers to the important clinical challenges of today. Copyright (c) 2010 Elsevier Ltd. All rights reserved.

'Oh my God, I can't handle this!': trainees' emotional responses to complex situations.

PubMed

Helmich, Esther; Diachun, Laura; Joseph, Radha; LaDonna, Kori; Noeverman-Poel, Nelleke; Lingard, Lorelei; Cristancho, Sayra

2018-02-01

Dealing with emotions is critical for medical trainees' professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations. In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants' perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a 'gallery walk', and using the interviews to inform the aesthetic analysis. Participants' drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families. A sense of control seems to be a key factor influencing trainees' emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will 'grow out of' with expertise. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Complex adaptive systems (CAS): an overview of key elements, characteristics and application to management theory.

PubMed

Ellis, Beverley; Herbert, Stuart Ian

2011-01-01

To identify key elements and characteristics of complex adaptive systems (CAS) relevant to implementing clinical governance, drawing on lessons from quality improvement programmes and the use of informatics in primary care. The research strategy includes a literature review to develop theoretical models of clinical governance of quality improvement in primary care organisations (PCOs) and a survey of PCOs. Complex adaptive system theories are a valuable tool to help make sense of natural phenomena, which include human responses to problem solving within the sampled PCOs. The research commenced with a survey; 76% (n16) of respondents preferred to support the implementation of clinical governance initiatives guided by outputs from general practice electronic health records. There was considerable variation in the way in which consultation data was captured, recorded and organised. Incentivised information sharing led to consensus on coding policies and models of data recording ahead of national contractual requirements. Informatics was acknowledged as a mechanism to link electronic health record outputs, quality improvement and resources. Investment in informatics was identified as a development priority in order to embed clinical governance principles in practice. Complex adaptive system theory usefully describes evolutionary change processes, providing insight into how the origins of quality assurance were predicated on rational reductionism and linearity. New forms of governance do not neutralise previous models, but add further dimensions to them. Clinical governance models have moved from deterministic and 'objective' factors to incorporate cultural aspects with feedback about quality enabled by informatics. The socio-technical lessons highlighted should inform healthcare management.

Basics of Compounding: Clinical Pharmaceutics, Part 1.

PubMed

Allen, Loyd V

2016-01-01

Pharmaceutics is relevant far beyond the pharmaceutical industry, compounding, and the laboratory. Pharmaceutics can be used to solve many clinical problems in medication therapy. A pharmacists' knowledge of the physicochemical aspects of drugs and drug products should help the patient, physician, and healthcare professionals resolve issues in the increasingly complex world of modern medicine. Pharmacy is unique as it contains a knowledge base significantly different from that of physicians, nurses, and other health-related practitioners. The separation of the science and the practice of pharmacy have prevented the complete utilization of pharmaceutical sciences in the clinical environment far too long. Copyright© by International Journal of Pharmaceutical Compounding, Inc.

[Clinical management of child and adolescent psychiatric emergencies in patients with substance abuse disorders].

PubMed

Coronel, Pablo A

2017-01-01

This paper addresses the problem of substance abuse disorders in child and adolescent patients within its frequent psychiatric emergency setting. It describes the clinical features that defne the high complexity of these cases, the current state of knowledge regarding clinical management of child and adolescent psychiatric emergencies in patients with substance abuse disorders, and the available treatment strategies in the metropolitan area of Buenos Aires, Argentina. Finally, this article delves into the existence of a metropolitan addiction treatment network, its community outreach and the obstacles it has to conquer in order to attain the international standards for the treatment of substance abuse disorders.

Basics of Compounding: Clinical Pharmaceutics, Part 2.

PubMed

Allen, Loyd V

2016-01-01

This article represents part 2 of a 2-part article on the topic of clinical pharmaceutics. Pharmaceutics is relevant far beyond the pharmaceutical industry, compounding, and the laboratory. Pharmaceutics can be used to solve many clinical problems in medication therapy. A pharmacists' knowledge of the physicochemical aspects of drugs and drug products should help the patient, physician, and healthcare professionals resolve issues in the increasingly complex world of modern medicine. Part 1 of this series of articles discussed incompatibilities which can directly affect a clinical outcome and utilized pharmaceutics case examples of the application and importance of clinical pharmaceutics covering different characteristics. Part 2 continues to illustrate the scientific principles and clinical effects involved in clinical pharmaceutics. Also covered in this article are many of the scientific principles in typical to patient care. Copyright© by International Journal of Pharmaceutical Compounding, Inc.

Iatrogenics in Orthodontics and its challenges.

PubMed

Barreto, Gustavo Mattos; Feitosa, Henrique Oliveira

2016-01-01

Orthodontics has gone through remarkable advances for those who practice it with dignity and clinical quality, such as the unprecedented number of patients treated of some type of iatrogenic problems (post-treatment root resorptions; occlusal plane changes; midline discrepancies, asymmetries, etc). Several questions may raise useful reflections about the constant increase of iatrogenics. What is causing it? Does it occur when dentists are properly trained? In legal terms, how can dentists accept these patients? How should they be orthodontically treated? What are the most common problems? This study analyzed and discussed relevant aspects to understand patients with iatrogenic problems and describe a simple and efficient approach to treat complex cases associated with orthodontic iatrogenics.

Iatrogenics in Orthodontics and its challenges

PubMed Central

Barreto, Gustavo Mattos; Feitosa, Henrique Oliveira

2016-01-01

ABSTRACT Introduction: Orthodontics has gone through remarkable advances for those who practice it with dignity and clinical quality, such as the unprecedented number of patients treated of some type of iatrogenic problems (post-treatment root resorptions; occlusal plane changes; midline discrepancies, asymmetries, etc). Several questions may raise useful reflections about the constant increase of iatrogenics. What is causing it? Does it occur when dentists are properly trained? In legal terms, how can dentists accept these patients? How should they be orthodontically treated? What are the most common problems? Objective: This study analyzed and discussed relevant aspects to understand patients with iatrogenic problems and describe a simple and efficient approach to treat complex cases associated with orthodontic iatrogenics. PMID:27901237

Early in-session cognitive-emotional problem-solving predicts 12-month outcomes in depression with personality disorder.

PubMed

McCarthy, Kye L; Mergenthaler, Erhard; Grenyer, Brin F S

2014-01-01

Therapist-patient verbalizations reveal complex cognitive-emotional linguistic data. How these variables contribute to change requires further research. Emotional-cognitive text analysis using the Ulm cycles model software was applied to transcripts of the third session of psychotherapy for 20 patients with depression and personality disorder. Results showed that connecting cycle sequences of problem-solving in the third hour predicted 12-month clinical outcomes. Therapist-patient dyads most improved spent significantly more time early in session in connecting cycles, whilst the least improved moved into connecting cycles late in session. For this particular sample, it was clear that positive emotional problem-solving in therapy was beneficial.

A clinical study on "Computer vision syndrome" and its management with Triphala eye drops and Saptamrita Lauha.

PubMed

Gangamma, M P; Poonam; Rajagopala, Manjusha

2010-04-01

American Optometric Association (AOA) defines computer vision syndrome (CVS) as "Complex of eye and vision problems related to near work, which are experienced during or related to computer use". Most studies indicate that Video Display Terminal (VDT) operators report more eye related problems than non-VDT office workers. The causes for the inefficiencies and the visual symptoms are a combination of individual visual problems and poor office ergonomics. In this clinical study on "CVS", 151 patients were registered, out of whom 141 completed the treatment. In Group A, 45 patients had been prescribed Triphala eye drops; in Group B, 53 patients had been prescribed the Triphala eye drops and SaptamritaLauha tablets internally, and in Group C, 43 patients had been prescribed the placebo eye drops and placebo tablets. In total, marked improvement was observed in 48.89, 54.71 and 06.98% patients in groups A, B and C, respectively.

Deep learning based syndrome diagnosis of chronic gastritis.

PubMed

Liu, Guo-Ping; Yan, Jian-Jun; Wang, Yi-Qin; Zheng, Wu; Zhong, Tao; Lu, Xiong; Qian, Peng

2014-01-01

In Traditional Chinese Medicine (TCM), most of the algorithms used to solve problems of syndrome diagnosis are superficial structure algorithms and not considering the cognitive perspective from the brain. However, in clinical practice, there is complex and nonlinear relationship between symptoms (signs) and syndrome. So we employed deep leaning and multilabel learning to construct the syndrome diagnostic model for chronic gastritis (CG) in TCM. The results showed that deep learning could improve the accuracy of syndrome recognition. Moreover, the studies will provide a reference for constructing syndrome diagnostic models and guide clinical practice.

Interprofessional collaboration in research, education, and clinical practice: working together for a better future.

PubMed

Green, Bart N; Johnson, Claire D

2015-03-01

Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and is often used as a means for solving a variety of problems and complex issues. The benefits of collaboration allow participants to achieve together more than they can individually, serve larger groups of people, and grow on individual and organizational levels. This editorial provides an overview of interprofessional collaboration in the areas of clinical practice, education, and research; discusses barriers to collaboration; and suggests potential means to overcome them.

Deep Learning Based Syndrome Diagnosis of Chronic Gastritis

PubMed Central

Liu, Guo-Ping; Wang, Yi-Qin; Zheng, Wu; Zhong, Tao; Lu, Xiong; Qian, Peng

2014-01-01

In Traditional Chinese Medicine (TCM), most of the algorithms used to solve problems of syndrome diagnosis are superficial structure algorithms and not considering the cognitive perspective from the brain. However, in clinical practice, there is complex and nonlinear relationship between symptoms (signs) and syndrome. So we employed deep leaning and multilabel learning to construct the syndrome diagnostic model for chronic gastritis (CG) in TCM. The results showed that deep learning could improve the accuracy of syndrome recognition. Moreover, the studies will provide a reference for constructing syndrome diagnostic models and guide clinical practice. PMID:24734118

Interprofessional collaboration in research, education, and clinical practice: working together for a better future

PubMed Central

Green, Bart N.; Johnson, Claire D.

2015-01-01

Interprofessional collaboration occurs when 2 or more professions work together to achieve common goals and is often used as a means for solving a variety of problems and complex issues. The benefits of collaboration allow participants to achieve together more than they can individually, serve larger groups of people, and grow on individual and organizational levels. This editorial provides an overview of interprofessional collaboration in the areas of clinical practice, education, and research; discusses barriers to collaboration; and suggests potential means to overcome them. PMID:25594446

Clinic-friendly screening for cognitive and mental health problems in school-aged youth with epilepsy.

PubMed

Asato, Miya R; Doss, Julia L; Plioplys, Sigita

2015-07-01

Cognitive, psychiatric, psychosocial, and behavioral difficulties are common in youth with epilepsy. Collectively, these comorbidities can be referred to as mental health problems as they reflect brain and behavioral function. Detection and treatment of mental health problems remain an unmet need in epilepsy care that can impact epilepsy, psychosocial, scholastic, and quality-of-life outcomes. Given limited resources in everyday pediatric epilepsy practice, this targeted review provides a stratified plan and suggested tools for screening school-aged youth with epilepsy for the presence of mental health problems. Comanagement of epilepsy and associated comorbidities is a newer concept that may help address the complex, long-term needs of patients by using a multidisciplinary team approach and by engaging primary care providers. Copyright © 2015 Elsevier Inc. All rights reserved.

Stock management in hospital pharmacy using chance-constrained model predictive control.

PubMed

Jurado, I; Maestre, J M; Velarde, P; Ocampo-Martinez, C; Fernández, I; Tejera, B Isla; Prado, J R Del

2016-05-01

One of the most important problems in the pharmacy department of a hospital is stock management. The clinical need for drugs must be satisfied with limited work labor while minimizing the use of economic resources. The complexity of the problem resides in the random nature of the drug demand and the multiple constraints that must be taken into account in every decision. In this article, chance-constrained model predictive control is proposed to deal with this problem. The flexibility of model predictive control allows taking into account explicitly the different objectives and constraints involved in the problem while the use of chance constraints provides a trade-off between conservativeness and efficiency. The solution proposed is assessed to study its implementation in two Spanish hospitals. Copyright © 2015 Elsevier Ltd. All rights reserved.

The Daily Readiness Huddle: a process to rapidly identify issues and foster improvement through problem-solving accountability.

PubMed

Donnelly, Lane F; Cherian, Shirley S; Chua, Kimberly B; Thankachan, Sam; Millecker, Laura A; Koroll, Alex G; Bisset, George S

2017-01-01

Because of the increasing complexities of providing imaging for pediatric health care services, a more reliable process to manage the daily delivery of care is necessary. Objective We describe our Daily Readiness Huddle and the effects of the process on problem identification and improvement. Our Daily Readiness Huddle has four elements: metrics review, clinical volume review, daily readiness assessment, and problem accountability. It is attended by radiologists, directors, managers, front-line staff with concerns, representatives from support services (information technology [IT] and biomedical engineering [biomed]), and representatives who join the meeting in a virtual format from off-site locations. Data are visually displayed on erasable whiteboards. The daily readiness assessment uses queues to determine whether anyone has concerns or outlier data in regard to S-MESA (Safety, Methods, Equipment, Supplies or Associates). Through this assessment, problems are identified and categorized as quick hits (will be resolved in 24-48 h, not requiring project management) and complex issues. Complex issues are assigned an owner, quality coach and report-back date. Additionally, projects are defined as improvements that are often strategic, are anticipated to take more than 60 days, and do not necessarily arise out of identified issues during the Daily Readiness Huddle. We tracked and calculated the mean, median and range of days to resolution and completion for complex issues and for projects during the first full year of implementing this process. During the first 12 months, 91 complex issues were identified and resolved, 11 projects were in progress and 33 completed, with 23 other projects active or in planning. Time to resolution of complex issues (in days) was mean 37.5, median 34.0, and range 1-105. For projects, time to completion (in days) was mean 86.0, median 84.0, and range 5-280. The Daily Readiness Huddle process has given us a framework to rapidly identify issues, bring accountability to problem-solving, and foster improvement. It has also had a positive effect on team-building and coordination.

Information technology and social sciences: how can health IT be used to support the health professional?

PubMed

Wagner-Menghin, Michaela; Pokieser, Peter

2016-10-01

Keeping up to date with the increasing amount of health-related knowledge and managing the increasing numbers of patients with more complex clinical problems is a challenge for healthcare professionals and healthcare systems. Health IT applications, such as electronic health records or decision-support systems, are meant to support both professionals and their support systems. However, for physicians using these applications, the applications often cause new problems, such as the impracticality of their use in clinical practice. This review adopts a social sciences perspective to understand these problems and derive suggestions for further development. Indeed, humans use tools to remediate the brain's weaknesses and enhance thinking. Available health IT tools have been shaped to fit administrative needs rather than physicians' needs. To increase the beneficial effect of health IT applications in health care, clinicians' style of thinking and their learning needs must be considered when designing and implementing such systems. New health IT tools must be shaped to fit health professionals' needs. To further ease the integration of new health IT tools into clinical practice, we must also consider the effects of implementing new tools on the wider social framework. © 2016 New York Academy of Sciences.

Motion Artefacts in MRI: a Complex Problem with Many Partial Solutions

PubMed Central

Zaitsev, Maxim; Maclaren, Julian.; Herbst, Michael

2015-01-01

Subject motion during magnetic resonance imaging (MRI) has been problematic since its introduction as a clinical imaging modality. While sensitivity to particle motion or blood flow can be used to provide useful image contrast, bulk motion presents a considerable problem in the majority of clinical applications. It is one of the most frequent sources of artefacts. Over 30 years of research have produced numerous methods to mitigate or correct for motion artefacts, but no single method can be applied in all imaging situations. Instead, a ‘toolbox’ of methods exists, where each tool is suitable for some tasks, but not for others. This article reviews the origins of motion artefacts and presents current mitigation and correction methods. In some imaging situations, the currently available motion correction tools are highly effective; in other cases, appropriate tools still need to be developed. It seems likely that this multifaceted approach will be what eventually solves the motion sensitivity problem in MRI, rather than a single solution that is effective in all situations. This review places a strong emphasis on explaining the physics behind the occurrence of such artefacts, with the aim of aiding artefact detection and mitigation in particular clinical situations. PMID:25630632

Motion artifacts in MRI: A complex problem with many partial solutions.

PubMed

Zaitsev, Maxim; Maclaren, Julian; Herbst, Michael

2015-10-01

Subject motion during magnetic resonance imaging (MRI) has been problematic since its introduction as a clinical imaging modality. While sensitivity to particle motion or blood flow can be used to provide useful image contrast, bulk motion presents a considerable problem in the majority of clinical applications. It is one of the most frequent sources of artifacts. Over 30 years of research have produced numerous methods to mitigate or correct for motion artifacts, but no single method can be applied in all imaging situations. Instead, a "toolbox" of methods exists, where each tool is suitable for some tasks, but not for others. This article reviews the origins of motion artifacts and presents current mitigation and correction methods. In some imaging situations, the currently available motion correction tools are highly effective; in other cases, appropriate tools still need to be developed. It seems likely that this multifaceted approach will be what eventually solves the motion sensitivity problem in MRI, rather than a single solution that is effective in all situations. This review places a strong emphasis on explaining the physics behind the occurrence of such artifacts, with the aim of aiding artifact detection and mitigation in particular clinical situations. © 2015 Wiley Periodicals, Inc.

The procurement of cells for the derivation of human embryonic stem cell lines for therapeutic use: recommendations for good practice.

PubMed

Murdoch, Alison; Braude, Peter; Courtney, Aidan; Brison, Daniel; Hunt, Charles; Lawford-Davies, James; Moore, Harry; Stacey, Glyn; Sethe, Sebastian

2012-03-01

The donation of human embryos for the derivation of embryonic stem cell lines that may be used in the development of therapeutic products raises more complex ethical, practical and regulatory problems than the donation of embryos for non-clinical research. This review considers these issues and offers recommendations for good practice.

Incivility in nursing: the connection between academia and clinical settings.

PubMed

Luparell, Susan

2011-04-01

Incivility and bullying in nursing are complex problems that have garnered much attention in recent years. Emerging evidence suggests that incivility in the workplace has significant implications for nurses, patients, and health care organizations. Because today's students are tomorrow's colleagues, conversations regarding how to address incivility and bullying should include specific aspects of nursing academia and the preparation of new nurses.

The use of high-fidelity human patient simulation as an evaluative tool in the development of clinical research protocols and procedures.

PubMed

Wright, Melanie C; Taekman, Jeffrey M; Barber, Linda; Hobbs, Gene; Newman, Mark F; Stafford-Smith, Mark

2005-12-01

Errors in clinical research can be costly, in terms of patient safety, data integrity, and data collection. Data inaccuracy in early subjects of a clinical study may be associated with problems in the design of the protocol, procedures, and data collection tools. High-fidelity patient simulation centers provide an ideal environment to apply human-centered design to clinical trial development. A draft of a complex clinical protocol was designed, evaluated and modified using a high-fidelity human patient simulator in the Duke University Human Simulation and Patient Safety Center. The process included walk-throughs, detailed modifications of the protocol and development of procedural aids. Training of monitors and coordinators provided an opportunity for observation of performance that was used to identify further improvements to the protocol. Evaluative steps were used to design the research protocol and procedures. Iterative modifications were made to the protocol and data collection tools. The success in use of human simulation in the preparation of a complex clinical drug trial suggests the benefits of human patient simulation extend beyond training and medical equipment evaluation. Human patient simulation can provide a context for informal expert evaluation of clinical protocol design and for formal "rehearsal" to evaluate the efficacy of procedures and support tools.

[Clinical reasoning in nursing, concept analysis].

PubMed

Côté, Sarah; St-Cyr Tribble, Denise

2012-12-01

Nurses work in situations of complex care requiring great clinical reasoning abilities. In literature, clinical reasoning is often confused with other concepts and it has no consensual definition. To conduct a concept analysis of a nurse's clinical reasoning in order to clarify, define and distinguish it from the other concepts as well as to better understand clinical reasoning. Rodgers's method of concept analysis was used, after literature was retrieved with the use of clinical reasoning, concept analysis, nurse, intensive care and decision making as key-words. The use of cognition, cognitive strategies, a systematic approach of analysis and data interpretation, generating hypothesis and alternatives are attributes of clinical reasoning. The antecedents are experience, knowledge, memory, cues, intuition and data collection. The consequences are decision making, action, clues and problem resolution. This concept analysis helped to define clinical reasoning, to distinguish it from other concepts used synonymously and to guide future research.

Team Learning for Healthcare Quality Improvement

PubMed Central

Eppstein, Margaret J.; Horbar, Jeffrey D.

2014-01-01

In organized healthcare quality improvement collaboratives (QICs), teams of practitioners from different hospitals exchange information on clinical practices with the aim of improving health outcomes at their own institutions. However, what works in one hospital may not work in others with different local contexts because of nonlinear interactions among various demographics, treatments, and practices. In previous studies of collaborations where the goal is a collective problem solving, teams of diverse individuals have been shown to outperform teams of similar individuals. However, when the purpose of collaboration is knowledge diffusion in complex environments, it is not clear whether team diversity will help or hinder effective learning. In this paper, we first use an agent-based model of QICs to show that teams comprising similar individuals outperform those with more diverse individuals under nearly all conditions, and that this advantage increases with the complexity of the landscape and level of noise in assessing performance. Examination of data from a network of real hospitals provides encouraging evidence of a high degree of similarity in clinical practices, especially within teams of hospitals engaging in QIC teams. However, our model also suggests that groups of similar hospitals could benefit from larger teams and more open sharing of details on clinical outcomes than is currently the norm. To facilitate this, we propose a secure virtual collaboration system that would allow hospitals to efficiently identify potentially better practices in use at other institutions similar to theirs without any institutions having to sacrifice the privacy of their own data. Our results may also have implications for other types of data-driven diffusive learning such as in personalized medicine and evolutionary search in noisy, complex combinatorial optimization problems. PMID:25360395

Oversight of human participants research: identifying problems to evaluate reform proposals.

PubMed

Emanuel, Ezekiel J; Wood, Anne; Fleischman, Alan; Bowen, Angela; Getz, Kenneth A; Grady, Christine; Levine, Carol; Hammerschmidt, Dale E; Faden, Ruth; Eckenwiler, Lisa; Muse, Carianne Tucker; Sugarman, Jeremy

2004-08-17

The oversight of research involving human participants is widely believed to be inadequate. The U.S. Congress, national commissions, the Department of Health and Human Services, the Institute of Medicine, numerous professional societies, and others are proposing remedies based on the assumption that the main problems are researchers' conflict of interest, lack of institutional review board (IRB) resources, and the volume and complexity of clinical research. Developing appropriate reform proposals requires carefully delineating the problems of the current system to know what reforms are needed. To stimulate a more informed and meaningful debate, we delineate 15 current problems into 3 broad categories. First, structural problems encompass 8 specific problems related to the way the research oversight system is organized. Second, procedural problems constitute 5 specific problems related to the operations of IRB review. Finally, performance assessment problems include 2 problems related to absence of systematic assessment of the outcomes of the oversight system. We critically assess proposed reforms, such as accreditation and central IRBs, according to how well they address these 15 problems. None of the reforms addresses all 15 problems. Indeed, most focus on the procedural problems, failing to address either the structure or the performance assessment problems. Finally, on the basis of the delineation of problems, we outline components of a more effective reform proposal, including bringing all research under federal oversight, a permanent advisory committee to address recurrent ethical issues in clinical research, mandatory single-time review for multicenter research protocols, additional financial support for IRB functions, and a standardized system for collecting and disseminating data on both adverse events and the performance assessment of IRBs.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences.

PubMed

Hunt, Isabelle M; Clements, Caroline; Saini, Pooja; Rahman, Mohammad Shaiyan; Shaw, Jenny; Appleby, Louis; Kapur, Nav; Windfuhr, Kirsten

2016-06-01

Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients. To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff. A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff. Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors. Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

Neighborhood graph and learning discriminative distance functions for clinical decision support.

PubMed

Tsymbal, Alexey; Zhou, Shaohua Kevin; Huber, Martin

2009-01-01

There are two essential reasons for the slow progress in the acceptance of clinical case retrieval and similarity search-based decision support systems; the especial complexity of clinical data making it difficult to define a meaningful and effective distance function on them and the lack of transparency and explanation ability in many existing clinical case retrieval decision support systems. In this paper, we try to address these two problems by introducing a novel technique for visualizing inter-patient similarity based on a node-link representation with neighborhood graphs and by considering two techniques for learning discriminative distance function that help to combine the power of strong "black box" learners with the transparency of case retrieval and nearest neighbor classification.

Relevance of Rodent Models of Depression in Clinical Practice: Can We Overcome the Obstacles in Translational Neuropsychiatry?

PubMed

Söderlund, Johan; Lindskog, Maria

2018-04-23

The diagnosis of a mental disorder generally depends on clinical observations and phenomenological symptoms reported by the patient. The definition of a given diagnosis is criteria based and relies on the ability to accurately interpret subjective symptoms and complex behavior. This type of diagnosis comprises a challenge to translate to reliable animal models, and these translational uncertainties hamper the development of new treatments. In this review, we will discuss how depressive-like behavior can be induced in rodents, and the relationship between these models and depression in humans. Specifically, we suggest similarities between triggers of depressive-like behavior in animal models and human conditions known to increase the risk of depression, for example exhaustion and bullying. Although we acknowledge the potential problems in comparing animal findings to human conditions, such comparisons are useful for understanding the complexity of depression, and we highlight the need to develop clinical diagnoses and animal models in parallel to overcome translational uncertainties.

Anatomy and physiology of the liver in relation to clinical assessment.

PubMed

Pierce, L

1977-06-01

As nurses assume expanded roles in patient care, skills in history-taking and in performing a physical examination are expected. Of the various diagnostic procedures the history and physical examination are the most direct and expeditious methods of obtaining facts about patients' problems. As represented in this article, detailed knowledge of the liver's anatomy and physiology as well as that of other body systems is prerequisite to these skills. To understand and document the complexity of life disturbances occuring in patients with hepatic problems, integration of social-behavioral and mental health concepts is needed.

Physician decision-making in the management of work related upper extremity injuries.

PubMed

Szekeres, Mike; Macdermid, Joy C; Katchky, Adam; Grewal, Ruby

2018-05-22

Physicians working in a tertiary care injured worker clinic are faced with clinical decision-making that must balance the needs of patients and society in managing complex clinical problems that are complicated by the work-workplace context. The purpose of this study is to describe and characterize the decision-making process of upper extremity specialized surgeons when managing injured workers within a specialized worker's compensation clinic. Surgeons were interviewed in a semi-structured manner. Following each interview, the surgeon was also observed in a clinic visit during a new patient assessment, allowing observation of the interactional patterns between surgeon and patient, and comparison of the process described in the interview to what actually occurred during clinic visits. The primary central theme emerging from the surgeon interviews and the clinical observation was the focus on the importance of comprehensive assessment to make the first critical decision: an accurate diagnosis. Two subthemes were also found. The first of these involved the decision whether to proceed to management strategies or to continue with further investigation if the correct diagnosis is uncertain. Once the central theme of diagnosis was achieved, a second subtheme was highlighted; selecting appropriate management options, given the complexities of managing the injured worker, the workplace, and the compensation board. This study illustrates that upper extremity surgeons rely on their training and experience with upper extremity conditions to follow a sequential but iterative decision-making process to provide a more definitive diagnosis and treatment plan for workers with injuries that are often complex. The surgeons are challenged by the context which takes them out of their familiar zone of typical clinical practice to deal with the interactions between the injury, worker, work, workplace and insurer.

Has NICE got it right? An international perspective considering the case of Technology Appraisal No. 98 by the National Institute for Health and Clinical Excellence (NICE).

PubMed

Schlander, Michael

2008-04-01

The National Institute for Health and Clinical Excellence (NICE) has been widely recognised as setting an international standard for high-quality health technology assessments (HTAs) including economic evaluation. A previous critical analysis of NICE Technology Appraisal No. 98 (TA98), evaluating methylphenidate, dexamphetamine and atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, revealed a number of issues, which must cast doubt on the robustness of the NICE approach when addressing a complex clinical decision problem. The exploration of potential underlying problems will be followed by a discussion of lessons for international healthcare policy-makers, and is intended to be an invitation to further debate and inquiry, not a presentation of definitive conclusions. Pertaining to the technology assessment report, potential problems were identified relating to an unnecessarily narrow scope, data search and selection strategy, the distinction between efficacy and effectiveness, data synthesis across studies and clinical effect measures, and limitations of the economic model. The appraisal process moderated the asserted 'clear conclusions' of the assessment but could not compensate for some of its gaps. It is suggested that key issues contributing to these problems may have included a separation of clinical and economic perspectives, a highly standardised reference case analysis that was followed schematically, the absence of an effective system for quality assurance of technology assessments, and transparency deficits of the economic evaluation. Further considerations for international policy-makers looking at NICE as a potential role model for HTAs are discussed, such as institutional context, the objectives of collectively financed healthcare and related value judgments, the reliance on QALYs as a universal and comprehensive measure of health benefits, the appropriate perspective for analysis, and process-related implications.

Recurring Vivid Dreams in an Older Hmong Man With Complex Trauma Experience and Cognitive Impairment.

PubMed

Askar, Wajih; Khan, Ariba; Borson, Soo; Malone, Michael L

2017-08-01

Health care workers need to consider the culture and ethnic preferences prevalent in the Hmong community in order to provide optimal care. We describe an older Hmong man to illustrate the challenges faced and competencies needed by primary care. An 80-year-old non-English speaking Hmong man with diabetes, nerve sheath tumor, and hypertension presented to the outpatient clinic with his grandson complaining of sleep problems. He had had 2 vivid recurring dreams during the previous few months. Memory assessment was significant for dementia. This case addresses the complexity in taking care of a non-English speaking Hmong older man who has memory loss, trauma in adulthood, multiple caregivers, and sleep problems. A careful history from patient and family to get to know their cultural preferences and attitudes was helpful. Identification of the primary caregiver was critical in providing care.

Assessing organizational capacity for achieving meaningful use of electronic health records.

PubMed

Shea, Christopher M; Malone, Robb; Weinberger, Morris; Reiter, Kristin L; Thornhill, Jonathan; Lord, Jennifer; Nguyen, Nicholas G; Weiner, Bryan J

2014-01-01

Health care institutions are scrambling to manage the complex organizational change required for achieving meaningful use (MU) of electronic health records (EHR). Assessing baseline organizational capacity for the change can be a useful step toward effective planning and resource allocation. The aim of this article is to describe an adaptable method and tool for assessing organizational capacity for achieving MU of EHR. Data on organizational capacity (people, processes, and technology resources) and barriers are presented from outpatient clinics within one integrated health care delivery system; thus, the focus is on MU requirements for eligible professionals, not eligible hospitals. We conducted 109 interviews with representatives from 46 outpatient clinics. Most clinics had core elements of the people domain of capacity in place. However, the process domain was problematic for many clinics, specifically, capturing problem lists as structured data and having standard processes for maintaining the problem list in the EHR. Also, nearly half of all clinics did not have methods for tracking compliance with their existing processes. Finally, most clinics maintained clinical information in multiple systems, not just the EHR. The most common perceived barriers to MU for eligible professionals included EHR functionality, changes to workflows, increased workload, and resistance to change. Organizational capacity assessments provide a broad institutional perspective and an in-depth clinic-level perspective useful for making resource decisions and tailoring strategies to support the MU change effort for eligible professionals.

Treatment algorithms and protocolized care.

PubMed

Morris, Alan H

2003-06-01

Excess information in complex ICU environments exceeds human decision-making limits and likely contributes to unnecessary variation in clinical care, increasing the likelihood of clinical errors. I reviewed recent critical care clinical trials searching for information about the impact of protocol use on clinically pertinent outcomes. Several recently published clinical trials illustrate the importance of distinguishing efficacy and effectiveness trials. One of these trials illustrates the danger of conducting effectiveness trials before the efficacy of an intervention is established. The trials also illustrate the importance of distinguishing guidelines and inadequately explicit protocols from adequately explicit protocols. Only adequately explicit protocols contain enough detail to lead different clinicians to the same decision when faced with the same clinical scenario. Differences between guidelines and protocols are important. Guidelines lack detail and provide general guidance that requires clinicians to fill in many gaps. Computerized or paper-based protocols are detailed and, when used for complex clinical ICU problems, can generate patient-specific, evidence-based therapy instructions that can be carried out by different clinicians with almost no interclinician variability. Individualization of patient therapy can be preserved by these protocols when they are driven by individual patient data. Explicit decision-support tools (eg, guidelines and protocols) have favorable effects on clinician and patient outcomes and can reduce the variation in clinical practice. Guidelines and protocols that aid ICU decision makers should be more widely distributed.

Stress in hospital medicine: a problem for key hospital staff.

PubMed

Allen, I

2001-08-01

Many factors which contribute to stress in the workplace apply to both consultants and ward sisters. Both groups find that their roles have become more complex while they have increasingly lost control of their own clinical and professional territory in a managerial culture. The erosion of the key relationship between consultants and ward sisters is of concern and the need for teamworking is insufficiently recognized.

An assessment of the demographic and clinical correlates of the dimensions of alcohol use behaviour.

PubMed

Smith, Gillian W; Shevlin, Mark; Murphy, Jamie; Houston, James E

2010-01-01

To identify population-based clinical and demographic correlates of alcohol use dimensions. Using data from a population-based sample of Great Britain (n = 7849), structural equation modelling (SEM) was used to identify associations between demographic and clinical variables and two competing dimensional models of the Alcohol Use Disorders Identification Test (AUDIT). A two-factor SEM fit best. In this model, Factor 1, alcohol consumption, was associated with male sex, younger age, lower educational attainment, generalized anxiety disorder (GAD) and suicide attempts. Factor 2, alcohol-related problems, was associated with the demographic variables (to a lesser extent) and to a wider range of clinical variables, including depressive episode, GAD, mixed anxiety and depressive disorder, obsessive compulsive disorder, phobia, suicidal thoughts and suicide attempts. The one-factor SEM was associated with demographic and all assessed clinical correlates; however, this model did not fit the data well. Two main conclusions justify the two-factor approach to alcohol use classification. First, the model fit was considerably superior and, second, the dimensions of alcohol consumption and alcohol-related problems vary considerably in their associations with measures of demographic and clinical risk. A one-factor representation of alcohol use, for instance, would fail to recognize that measures of affective/anxiety disorders are more consistently related to alcohol-related problems than to alcohol consumption. It is suggested therefore that to fully understand the complexity of alcohol use behaviour and its associated risk, future research should acknowledge the basic underlying dimensional structure of the construct.

Problems encountered with the use of simulation in an attempt to enhance interpretation of a secondary data source in epidemiologic mental health research

PubMed Central

2010-01-01

Background The longitudinal epidemiology of major depressive episodes (MDE) is poorly characterized in most countries. Some potentially relevant data sources may be underutilized because they are not conducive to estimating the most salient epidemiologic parameters. An available data source in Canada provides estimates that are potentially valuable, but that are difficult to apply in clinical or public health practice. For example, weeks depressed in the past year is assessed in this data source whereas episode duration would be of more interest. The goal of this project was to derive, using simulation, more readily interpretable parameter values from the available data. Findings The data source was a Canadian longitudinal study called the National Population Health Survey (NPHS). A simulation model representing the course of depressive episodes was used to reshape estimates deriving from binary and ordinal logistic models (fit to the NPHS data) into equations more capable of informing clinical and public health decisions. Discrete event simulation was used for this purpose. Whereas the intention was to clarify a complex epidemiology, the models themselves needed to become excessively complex in order to provide an accurate description of the data. Conclusions Simulation methods are useful in circumstances where a representation of a real-world system has practical value. In this particular scenario, the usefulness of simulation was limited both by problems with the data source and by inherent complexity of the underlying epidemiology. PMID:20796271

Organometallic iron complexes as potential cancer therapeutics.

PubMed

Mojžišová, Gabriela; Mojžiš, Ján; Vašková, Janka

2014-01-01

Metal-containing drugs have long been used for medicinal purposes in more or less empirical way. The potential of these anticancer agents has only been fully realised and explored since the discovery of the biological activity of cisplatin. Cisplatin and carboplatin have been two of the most successful anti-cancer agents ever developed, and are currently used to treat ovarian, lung and testicular cancers. They share certain side effects, so their clinical use is severely limited by dose-limiting toxicity. Inherent or acquired resistance is a second problem often associated with platinum-based drugs, with further limits of their clinical use. These problems have prompted chemists to employ different strategies in development of the new metal-based anticancer agents with different mechanisms of action. There are various metal complexes still under development and investigation for the future cancer treatment use. In the search for novel bio-organometallic molecules, iron containing anti-tumoral agents are enjoying an increasing interest and appear very promising as the potential drug candidates. Iron, as an essential cofactor in a number of enzymes and physiological processes, may be less toxic than non essential metals, such as platinum. Up to now, some of iron complexes have been tested as cytotoxic agents and found to be endowed with an antitumor activity in several in vitro tests (on cultured cancer cell lines) and few in vivo experiments (e. g. on Ehrlich's ascites carcinoma). Although the precise molecular mechanism is yet to be defined, a number of observations suggest that the reactive oxygen species can play important role in iron-induced cytotoxicty. This review covers some relevant examples of research on the novel iron complexes.

Knowledge bases, clinical decision support systems, and rapid learning in oncology.

PubMed

Yu, Peter Paul

2015-03-01

One of the most important benefits of health information technology is to assist the cognitive process of the human mind in the face of vast amounts of health data, limited time for decision making, and the complexity of the patient with cancer. Clinical decision support tools are frequently cited as a technologic solution to this problem, but to date useful clinical decision support systems (CDSS) have been limited in utility and implementation. This article describes three unique sources of health data that underlie fundamentally different types of knowledge bases which feed into CDSS. CDSS themselves comprise a variety of models which are discussed. The relationship of knowledge bases and CDSS to rapid learning health systems design is critical as CDSS are essential drivers of rapid learning in clinical care. Copyright © 2015 by American Society of Clinical Oncology.

Discrete event simulation modelling of patient service management with Arena

NASA Astrophysics Data System (ADS)

Guseva, Elena; Varfolomeyeva, Tatyana; Efimova, Irina; Movchan, Irina

2018-05-01

This paper describes the simulation modeling methodology aimed to aid in solving the practical problems of the research and analysing the complex systems. The paper gives the review of a simulation platform sand example of simulation model development with Arena 15.0 (Rockwell Automation).The provided example of the simulation model for the patient service management helps to evaluate the workload of the clinic doctors, determine the number of the general practitioners, surgeons, traumatologists and other specialized doctors required for the patient service and develop recommendations to ensure timely delivery of medical care and improve the efficiency of the clinic operation.

From Stats to Stage-Translational Research in Performing Arts Medicine.

PubMed

Ackermann, Bronwen J

2016-12-01

Medical Problems of Performing Artists, since its inception under the legendary Alice Brandfonbrener's guidance and vision, has always recognized the need for voices to be heard from the clinic, stage, and experimental research. This has been important in a relatively young field like performing arts medicine, where there is not yet a robust base of evidence to draw from for the complex range of physical, psychological, and institutional challenges that can affect performer health. Evidence-based medicine has long been described as using the best available research in conjunction with clinical expertise, while considering patient beliefs, characteristics, and circumstances.

Suicide and suicidal behaviour

PubMed Central

Turecki, Gustavo; Brent, David A.

2017-01-01

Summary Suicide is a complex public health problem of global dimension. Suicidal behaviour (SB) shows marked differences between genders, age groups, geographic regions and socio-political realities, and variably associates with different risk factors, underscoring likely etiological heterogeneity. Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological, sociological, and biological factors may facilitate the detection of high-risk individuals and assist in treatment selection. Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent SB; additionally, regular follow-up of suicide attempters by mental health services is key to prevent future SB. PMID:26385066

Algorithmic tools for interpreting vital signs.

PubMed

Rathbun, Melina C; Ruth-Sahd, Lisa A

2009-07-01

Today's complex world of nursing practice challenges nurse educators to develop teaching methods that promote critical thinking skills and foster quick problem solving in the novice nurse. Traditional pedagogies previously used in the classroom and clinical setting are no longer adequate to prepare nursing students for entry into practice. In addition, educators have expressed frustration when encouraging students to apply newly learned theoretical content to direct the care of assigned patients in the clinical setting. This article presents algorithms as an innovative teaching strategy to guide novice student nurses in the interpretation and decision making related to vital sign assessment in an acute care setting.

Medical students' personal experience of high-stakes failure: case studies using interpretative phenomenological analysis.

PubMed

Patel, R S; Tarrant, C; Bonas, S; Shaw, R L

2015-05-12

Failing a high-stakes assessment at medical school is a major event for those who go through the experience. Students who fail at medical school may be more likely to struggle in professional practice, therefore helping individuals overcome problems and respond appropriately is important. There is little understanding about what factors influence how individuals experience failure or make sense of the failing experience in remediation. The aim of this study was to investigate the complexity surrounding the failure experience from the student's perspective using interpretative phenomenological analysis (IPA). The accounts of three medical students who had failed final re-sit exams, were subjected to in-depth analysis using IPA methodology. IPA was used to analyse each transcript case-by-case allowing the researcher to make sense of the participant's subjective world. The analysis process allowed the complexity surrounding the failure to be highlighted, alongside a narrative describing how students made sense of the experience. The circumstances surrounding students as they approached assessment and experienced failure at finals were a complex interaction between academic problems, personal problems (specifically finance and relationships), strained relationships with friends, family or faculty, and various mental health problems. Each student experienced multi-dimensional issues, each with their own individual combination of problems, but experienced remediation as a one-dimensional intervention with focus only on improving performance in written exams. What these students needed to be included was help with clinical skills, plus social and emotional support. Fear of termination of the their course was a barrier to open communication with staff. These students' experience of failure was complex. The experience of remediation is influenced by the way in which students make sense of failing. Generic remediation programmes may fail to meet the needs of students for whom personal, social and mental health issues are a part of the picture.

Complex Problem Solving: What It Is and What It Is Not

PubMed Central

Dörner, Dietrich; Funke, Joachim

2017-01-01

Computer-simulated scenarios have been part of psychological research on problem solving for more than 40 years. The shift in emphasis from simple toy problems to complex, more real-life oriented problems has been accompanied by discussions about the best ways to assess the process of solving complex problems. Psychometric issues such as reliable assessments and addressing correlations with other instruments have been in the foreground of these discussions and have left the content validity of complex problem solving in the background. In this paper, we return the focus to content issues and address the important features that define complex problems. PMID:28744242

A Temporal Pattern Mining Approach for Classifying Electronic Health Record Data

PubMed Central

Batal, Iyad; Valizadegan, Hamed; Cooper, Gregory F.; Hauskrecht, Milos

2013-01-01

We study the problem of learning classification models from complex multivariate temporal data encountered in electronic health record systems. The challenge is to define a good set of features that are able to represent well the temporal aspect of the data. Our method relies on temporal abstractions and temporal pattern mining to extract the classification features. Temporal pattern mining usually returns a large number of temporal patterns, most of which may be irrelevant to the classification task. To address this problem, we present the Minimal Predictive Temporal Patterns framework to generate a small set of predictive and non-spurious patterns. We apply our approach to the real-world clinical task of predicting patients who are at risk of developing heparin induced thrombocytopenia. The results demonstrate the benefit of our approach in efficiently learning accurate classifiers, which is a key step for developing intelligent clinical monitoring systems. PMID:25309815

“Putting It All Together” to Improve Resuscitation Quality

PubMed Central

Sutton, Robert M.; Nadkarni, Vinay; Abella, Benjamin S.

2013-01-01

Cardiac arrest is a major public health problem affecting thousands of individuals each year in both the before hospital and in-hospital settings. However, although the scope of the problem is large, the quality of care provided during resuscitation attempts frequently does not meet quality of care standards, despite evidence-based cardiopulmonary resuscitation (CPR) guidelines, extensive provider training, and provider credentialing in resuscitation medicine. Although this fact may be disappointing, it should not be surprising. Resuscitation of the cardiac arrest victim is a highly complex task requiring coordination between various levels and disciplines of care providers during a stressful and relatively infrequent clinical situation. Moreover, it requires a targeted, high-quality response to improve clinical outcomes of patients. Therefore, solutions to improve care provided during resuscitation attempts must be multifaceted and targeted to the diverse number of care providers to be successful. PMID:22107978

An Assembled Nanocomplex for Improving both Therapeutic Efficiency and Treatment Depth in Photodynamic Therapy.

PubMed

Cao, Hongqian; Wang, Lei; Yang, Yang; Li, Juan; Qi, Yanfei; Li, Yue; Li, Ying; Wang, Hao; Li, Junbai

2018-06-25

Photodynamic therapy (PDT) shows unique selectivity and irreversible destruction toward treated tissues or cells, but still has several problems in clinical practice. One is limited therapeutic efficiency, which is attributed to hypoxia in tumor sites. Another is the limited treatment depth because traditional photosensitizes are excited by short wavelength light (<700 nm). An assembled nano-complex system composed of oxygen donor, two-photon absorption (TPA) species, and photosensitizer (PS) was synthesized to address both problems. The photosensitizer is excited indirectly by two-photon laser through intraparticle FRET mechanism for improving treatment depth. The oxygen donor, hemoglobin, can supply extra oxygen into tumor location through targeting effect for enhanced PDT efficiency. The mechanism and PDT effect were verified through both in vitro and in vivo experiments. The simple system is promising to promote two-photon PDT for clinical applications. © 2018 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

Reasons for missed appointments with a hepatitis C outreach clinic: A qualitative study.

PubMed

Poll, Ray; Allmark, Peter; Tod, Angela M

2017-01-01

Non-attendance in drug service hepatitis C outreach clinics means clients miss the opportunity of being given lifestyle advice and referral to hospital for assessment and treatment. A similar problem is experienced in other services throughout the UK. A qualitative study was undertaken to investigate the problem. Clients with a history of not attending the outreach clinic were invited to participate during a routine drug clinic appointment. A contact details sheet with a preferred telephone number was completed by those agreeing to take part. Verbal consent was taken and a telephone interview took place. The participants were remunerated for taking part with a five pounds high street voucher. The 'framework method' was used to analyse the data with key themes identified. Twenty-eight telephone interviews were undertaken from April to June 2012. All the clients gave 'prima-facie' reasons for non-attendance including 'not a priority' and 'forgot'. However, the study indicates these are insufficient to explain the various experiences and influences. Underlying reasons that impacted upon attendance were identified. These reasons relate to (i) client characteristics e.g. 'priority' to score drugs and the 'cost of travel' and (ii) clinic service e.g. 'difficult journey' to the clinic and timing of the 'appointment'. The reasons operated within a complex context where other factors had an impact including addiction, welfare policy, stigma and the nature of hepatitis C itself. The study revealed that beneath apparently simple explanations for non-attendance, such as clients' chaotic lifestyle resulting in them forgetting or not being bothered to attend, there were far more complex and varied underlying reasons. This has important implications for drug policy including the need to better incorporate clients' perspectives. Policy that is based only on the simple, surface reasons is unlikely to be effective. Crown Copyright © 2016. Published by Elsevier B.V. All rights reserved.

[Critical reflexion on quality improvement and networking].

PubMed

Adler, R

2012-06-06

Qualitiy-control and networking are two issues of debate in modern medicine. The origin of these terms is not to be found in medicine, but rather in industry. However their naive transfer to the field of medicine causes damage. It is relatively easy to test industrial products for their quality. Dealing with meaningful medical problems is far too complex. Simple data such as blood pressure, HbA1c, etc. may be assessed. The only means of quality-control of complex medical situations and actions are ward rounds by attending physicians, case presentations at staff meetings, etc. Issues of clinical quality-control are discussed on the basis of the history of an aged couple. Furthermore a personal clinical experience illustrates how doctors create a useful network with other physicians and how they eliminate "useless" colleagues from their network. Economists should have no influence or impact whatsoever on the quality-control and networking of physicians.

Prader-Willi Syndrome: Clinical Aspects

PubMed Central

Elena, Grechi; Bruna, Cammarata; Benedetta, Mariani; Stefania, Di Candia; Giuseppe, Chiumello

2012-01-01

Prader-Willi Syndrome (PWS) is a complex multisystem genetic disorder that shows great variability, with changing clinical features during a patient's life. The syndrome is due to the loss of expression of several genes encoded on the proximal long arm of chromosome 15 (15q11.2–q13). The complex phenotype is most probably caused by a hypothalamic dysfunction that is responsible for hormonal dysfunctions and for absence of the sense of satiety. For this reason a Prader-Willi (PW) child develops hyperphagia during the initial stage of infancy that can lead to obesity and its complications. During infancy many PW child display a range of behavioural problems that become more noticeable in adolescence and adulthood and interfere mostly with quality of life. Early diagnosis of PWS is important for effective long-term management, and a precocious multidisciplinary approach is fundamental to improve quality of life, prevent complications, and prolong life expectancy. PMID:23133744

Ground Truth Creation for Complex Clinical NLP Tasks - an Iterative Vetting Approach and Lessons Learned.

PubMed

Liang, Jennifer J; Tsou, Ching-Huei; Devarakonda, Murthy V

2017-01-01

Natural language processing (NLP) holds the promise of effectively analyzing patient record data to reduce cognitive load on physicians and clinicians in patient care, clinical research, and hospital operations management. A critical need in developing such methods is the "ground truth" dataset needed for training and testing the algorithms. Beyond localizable, relatively simple tasks, ground truth creation is a significant challenge because medical experts, just as physicians in patient care, have to assimilate vast amounts of data in EHR systems. To mitigate potential inaccuracies of the cognitive challenges, we present an iterative vetting approach for creating the ground truth for complex NLP tasks. In this paper, we present the methodology, and report on its use for an automated problem list generation task, its effect on the ground truth quality and system accuracy, and lessons learned from the effort.

Conducting clinical post-conference in clinical teaching: a qualitative study.

PubMed

Hsu, Li-Ling

2007-08-01

The aim of this study was to explore nurse educators' perceptions regarding clinical postconferences. Additional aims included the exploration of interaction characteristics between students and faculty in clinical postconferences. Nursing students are challenged to think and learn in ways that will prepare them for practice in a complex health care environment. Clinical postconferences give students the opportunity to share knowledge gained through transformative learning and provide a forum for discussion and critical thinking. Faculty members must guide students as the latter participate in discussions, develop problem-solving skills and express feedings and attitudes in clinical conferences. The study used qualitative research methods, including participant observation and an open-ended questionnaire. Participant observers watched interaction activities between teachers and students in clinical postconferences. A total of 20 clinical postconferences, two conferences per teacher, were observed. The Non-Numerical Unstructured Data Indexing Searching and Theory-building qualitative software program was used in data analysis. Research findings indicated that, of the six taxonomy questions, lower-level questions (knowledge and comprehensive questions) were mostly asked by faculty members' postclinical conferences. The most frequently used guideline was task orientation, which is related to practice goals and was found in discussions of assignments, reading reports, discussions of clinical experiences, role plays, psychomotor skill practice, quizzes and student evaluations. It is an essential responsibility of nurse educators to employ postconferences to assist students in applying their knowledge in practical situations, in developing professional values and in enhancing their problem solving abilities.

Carbohydrate-Based Host-Guest Complexation of Hydrophobic Antibiotics for the Enhancement of Antibacterial Activity.

PubMed

Jeong, Daham; Joo, Sang-Woo; Shinde, Vijay Vilas; Cho, Eunae; Jung, Seunho

2017-08-08

Host-guest complexation with various hydrophobic drugs has been used to enhance the solubility, permeability, and stability of guest drugs. Physical changes in hydrophobic drugs by complexation have been related to corresponding increases in the bioavailability of these drugs. Carbohydrates, including various derivatives of cyclodextrins, cyclosophoraoses, and some linear oligosaccharides, are generally used as host complexation agents in drug delivery systems. Many antibiotics with low bioavailability have some limitations to their clinical use due to their intrinsically poor aqueous solubility. Bioavailability enhancement is therefore an important step to achieve the desired concentration of antibiotics in the treatment of bacterial infections. Antibiotics encapsulated in a complexation-based drug delivery system will display improved antibacterial activity making it possible to reduce dosages and overcome the serious global problem of antibiotic resistance. Here, we review the present research trends in carbohydrate-based host-guest complexation of various hydrophobic antibiotics as an efficient delivery system to improve solubility, permeability, stability, and controlled release.

[The potential financial impact of oral health problems in the families of preschool children].

PubMed

Ribeiro, Gustavo Leite; Gomes, Monalisa Cesarino; de Lima, Kenio Costa; Martins, Carolina Castro; Paiva, Saul Martins; Granville-Garcia, Ana Flávia

2016-04-01

The aim of the study was to evaluate the perception of parents/caregivers regarding the financial impact of oral health problems on the families of preschool children. A preschool-based, cross-sectional study was conducted with 834 preschool children in Campina Grande, Brazil. Parents/caregivers answered the Early Childhood Oral Health Impact Scale. "Financial impact" was the dependent variable. Questionnaires addressing socio-demographic variables, history of toothache and health perceptions were administered. Clinical exams were performed by three dentists previously calibrated (Kappa: 0.85-0.90). Descriptive statistics were performed, followed by logistic regression for complex samples (α = 5%). The frequency of financial impact due to oral health problems in preschool children was 7.7%. The following variables were significantly associated with financial impact: parental perception of child's oral health as poor, the interaction between history of toothache and absence of dental caries and the interaction between history of toothache and presence of dental caries. It is concluded that often parents/caregivers reported experiencing a financial impact due to seeking treatment late, mainly by the presence of toothache and complications of the clinical condition.

[Postgraduate training for specialists in psychiatry and psychotherapy. Problem-based learning - evaluation of a pilot project].

PubMed

Rufer, M; Schnyder, U; Schirlo, C; Wengle, H; Gerke, W

2011-05-01

Problem-based learning (PBL) emphasizes the student's individual needs, their ability to solve complex clinical problems, and a professional attitude that facilitates communication among colleagues. Thus, PBL appears to provide a perfectly suitable didactic format for postgraduate training of medical specialties. To date, it is only rarely used in this area though. In a pilot project, we implemented PBL into the curriculum of postgraduate training in psychiatry and psychotherapy, and evaluated the program over a period of 12 months, using structured questionnaires. A total of 41 PBL courses were held, with 447 residents participating. Participants as well as tutors assessed 19 of 21 aspects as good or very good (5-point Likert scale, mean value >4). Overall, PBL was rated as highly suitable for advanced training (participants: 4.5±0.8; tutors: 5.0±0.2). The results of this pilot project suggest that PBL might be a useful element of multifaceted advanced training programs, strengthening their practical component and the applicability of knowledge in the daily clinical routine.

Treating the insomniac patient - General measures and psychological and pharmacological treatment

NASA Technical Reports Server (NTRS)

Kales, A.; Bixler, E. O.; Kales, J. D.

1975-01-01

The general preliminary measures for treating insomnia include moderate physical exercise several hours before bedtime, and the relaxation of complex mental activity before bedtime. A case history concerning a woman with marital troubles is offered as evidence that insomnia may be caused by deeply rooted psychological and situational problems. Another case history illustrates how prior pharmacological treatment may complicate the process of clinically evaluating an insomniac.

Convolving engineering and medical pedagogies for training of tomorrow's health care professionals.

PubMed

Lee, Raphael C

2013-03-01

Several fundamental benefits justify why biomedical engineering and medicine should form a more convergent alliance, especially for the training of tomorrow's physicians and biomedical engineers. Herein, we review the rationale underlying the benefits. Biological discovery has advanced beyond the era of molecular biology well into today's era of molecular systems biology, which focuses on understanding the rules that govern the behavior of complex living systems. This has important medical implications. To realize cost-effective personalized medicine, it is necessary to translate the advances in molecular systems biology to higher levels of biological organization (organ, system, and organismal levels) and then to develop new medical therapeutics based on simulation and medical informatics analysis. Higher education in biological and medical sciences must adapt to a new set of training objectives. This will involve a shifting away from reductionist problem solving toward more integrative, continuum, and predictive modeling approaches which traditionally have been more associated with engineering science. Future biomedical engineers and MDs must be able to predict clinical response to therapeutic intervention. Medical education will involve engineering pedagogies, wherein basic governing rules of complex system behavior and skill sets in manipulating these systems to achieve a practical desired outcome are taught. Similarly, graduate biomedical engineering programs will include more practical exposure to clinical problem solving.

Illness/injury pattern complex 40 (Titan)

NASA Technical Reports Server (NTRS)

Blasdell, Sharon

1993-01-01

On July 31, 1991, EG&G Medical began providing medical support at the Titan Area Clinic (TAC). The hours of operation are 0700-2300, Monday through Friday, with Emergency Medical Services (EMS) provided 24-hours a day, seven days a week. The TAC consists of a 10 x 10 ft section of a trailer that also houses Bechtel Safety. Supplies consisted of an examining table, an eye wash chair, first aid equipment, over-the-counter medications, spine boards, a portable rescuscitator, etc. All of the nurses are Advanced Cardiac Life Support (ACLS) certified. Although the Titan Area Clinic is strictly a first-aid station with no ACLS facilities on-site, it is staffed with an Occupational Health Nurse with ACLS certification. If ACLS or additional help is needed, the nurse activates EMS by dialing 911. The nurse responds to any medical problems or emergencies on the complex, but activates EMS prior to leaving the TAC. A Bechtel Safety Representative accompanies the nurse to the site and assists as needed. Other aspects of the complex and its functions are presented.

Development of Heat Shock Protein (Hsp90) Inhibitors To Combat Resistance to Tyrosine Kinase Inhibitors through Hsp90-Kinase Interactions.

PubMed

Wang, Meining; Shen, Aijun; Zhang, Chi; Song, Zilan; Ai, Jing; Liu, Hongchun; Sun, Liping; Ding, Jian; Geng, Meiyu; Zhang, Ao

2016-06-23

Heat shock protein 90 (Hsp90) is a ubiquitous chaperone of all of the oncogenic tyrosine kinases. Many Hsp90 inhibitors, alone or in combination, have shown significant antitumor efficacy against the kinase-positive naïve and mutant models. However, clinical trials of these inhibitors are unsuccessful due to insufficient clinical benefits and nonoptimal safety profiles. Recently, much progress has been reported on the Hsp90-cochaperone-client complex, which will undoubtedly assist in the understanding of the interactions between Hsp90 and its clients. Meanwhile, Hsp90 inhibitors have shown promise against patients' resistance caused by early generation tyrosine kinase inhibitors (TKIs), and at least 13 Hsp90 inhibitors are being reevaluated in the clinic. In this regard, the objectives of the current perspective are to summarize the structure and function of the Hsp90-cochaperone-client complex, to analyze the structural and functional insights into the Hsp90-client interactions to address several existing unresolved problems with Hsp90 inhibitors, and to highlight the preclinical and clinical studies of Hsp90 inhibitors as an effective treatment against resistance to tyrosine kinase inhibitors.

Recurrent mycobacterial osteomyelitis. Report of a case due to Mycobacterium avium-intracellulare-scrofulaceum complex and BCG vaccination.

PubMed

Solheim, L F; Kjelsberg, F

1982-01-01

A 28-year-old man suffering from recurrent mycobacterial osteomyelitis during several years is reported. Eight years old he had a Mycobacterium scrofulaceum infection in his right calcaneus. A serious infection with multiple foci of osteomyelitis occurred after BCG vaccination at the age of 14 years and 11 years later multifocal lesions of osteomyelitis due to Mycobacterium avium-intracellulare-scrofulaceum complex appeared. The special clinical problems due to the relative or complete resistence of these organisms to antituberculous drugs are emphasized. The mainstays of treatment are surgical revision and drainage with prolonged and intensive multiple drug therapy.

Bioprosthetic tissue matrices in complex abdominal wall reconstruction.

PubMed

Broyles, Justin M; Abt, Nicholas B; Sacks, Justin M; Butler, Charles E

2013-12-01

Complex abdominal defects are difficult problems encountered by surgeons in multiple specialties. Although current evidence supports the primary repair of these defects with mesh reinforcement, it is unclear which mesh is superior for any given clinical scenario. The purpose of this review was to explore the characteristics of and clinical relevance behind bioprosthetic tissue matrices in an effort to better clarify their role in abdominal wall reconstruction. We reviewed the peer-reviewed literature on the use of bioprosthetic mesh in human subjects. Basic science articles and large retrospective and prospective reviews were included in author's analysis. The clinical performance and characteristics of 13 bioprosthetic tissue matrices were evaluated. The majority of the products evaluated perform well in contaminated fields, where the risk of wound-healing difficulties is high. Clinical outcomes, which included infection, reherniation, and bulge formation, were variable, and the majority of the studies had a mean follow-up of less than 24 months. Although bioprosthetic matrix has a multitude of indications within the growing field of abdominal wall reconstruction, the functionality, regenerative capacity, and long-term fate of these products have yet to be fully established. Furthermore, the clinical performance, indications, and contraindications for each type of matrix need to be fully evaluated in long-term outcome studies.

Bioprosthetic Tissue Matrices in Complex Abdominal Wall Reconstruction

PubMed Central

Broyles, Justin M.; Abt, Nicholas B.; Sacks, Justin M.

2013-01-01

Background: Complex abdominal defects are difficult problems encountered by surgeons in multiple specialties. Although current evidence supports the primary repair of these defects with mesh reinforcement, it is unclear which mesh is superior for any given clinical scenario. The purpose of this review was to explore the characteristics of and clinical relevance behind bioprosthetic tissue matrices in an effort to better clarify their role in abdominal wall reconstruction. Methods: We reviewed the peer-reviewed literature on the use of bioprosthetic mesh in human subjects. Basic science articles and large retrospective and prospective reviews were included in author’s analysis. The clinical performance and characteristics of 13 bioprosthetic tissue matrices were evaluated. Results: The majority of the products evaluated perform well in contaminated fields, where the risk of wound-healing difficulties is high. Clinical outcomes, which included infection, reherniation, and bulge formation, were variable, and the majority of the studies had a mean follow-up of less than 24 months. Conclusions: Although bioprosthetic matrix has a multitude of indications within the growing field of abdominal wall reconstruction, the functionality, regenerative capacity, and long-term fate of these products have yet to be fully established. Furthermore, the clinical performance, indications, and contraindications for each type of matrix need to be fully evaluated in long-term outcome studies. PMID:25289285

The role of blended learning in the clinical education of healthcare students: a systematic review.

PubMed

Rowe, Michael; Frantz, Jose; Bozalek, Vivienne

2012-01-01

Developing practice knowledge in healthcare is a complex process that is difficult to teach. Clinical education exposes students to authentic learning situations, but students also need epistemological access to tacit knowledge and clinical reasoning skills in order to interpret clinical problems. Blended learning offers opportunities for the complexity of learning by integrating face-to-face and online interaction. However, little is known about its use in clinical education. To determine the impact of blended learning in the clinical education of healthcare students. Articles published between 2000 and 2010 were retrieved from online and print sources, and included multiple search methodologies. Search terms were derived following a preliminary review of relevant literature. A total of 71 articles were retrieved and 57 were removed after two rounds of analysis. Further methodological appraisals excluded another seven, leaving seven for the review. All studies reviewed evaluated the use of a blended learning intervention in a clinical context, although each intervention was different. Three studies included a control group, and two were qualitative in nature. Blended learning was shown to help bridge the gap between theory and practice and to improve a range of selected clinical competencies among students. Few high-quality studies were found to evaluate the role of blended learning in clinical education, and those that were found provide only rudimentary evidence that integrating technology-enhanced teaching with traditional approaches have potential to improve clinical competencies among health students. Further well-designed research into the use of blended learning in clinical education is therefore needed before we rush to adopt it.

The fractal heart — embracing mathematics in the cardiology clinic

PubMed Central

Captur, Gabriella; Karperien, Audrey L.; Hughes, Alun D.; Francis, Darrel P.; Moon, James C.

2017-01-01

For clinicians grappling with quantifying the complex spatial and temporal patterns of cardiac structure and function (such as myocardial trabeculae, coronary microvascular anatomy, tissue perfusion, myocyte histology, electrical conduction, heart rate, and blood-pressure variability), fractal analysis is a powerful, but still underused, mathematical tool. In this Perspectives article, we explain some fundamental principles of fractal geometry and place it in a familiar medical setting. We summarize studies in the cardiovascular sciences in which fractal methods have successfully been used to investigate disease mechanisms, and suggest potential future clinical roles in cardiac imaging and time series measurements. We believe that clinical researchers can deploy innovative fractal solutions to common cardiac problems that might ultimately translate into advancements for patient care. PMID:27708281

Application of Bayesian Approach in Cancer Clinical Trial

PubMed Central

Bhattacharjee, Atanu

2014-01-01

The application of Bayesian approach in clinical trials becomes more useful over classical method. It is beneficial from design to analysis phase. The straight forward statement is possible to obtain through Bayesian about the drug treatment effect. Complex computational problems are simple to handle with Bayesian techniques. The technique is only feasible to performing presence of prior information of the data. The inference is possible to establish through posterior estimates. However, some limitations are present in this method. The objective of this work was to explore the several merits and demerits of Bayesian approach in cancer research. The review of the technique will be helpful for the clinical researcher involved in the oncology to explore the limitation and power of Bayesian techniques. PMID:29147387

Seniors' perspectives on care: a case study of the Alex Seniors health clinic, Calgary.

PubMed

Shaw, Marta; Rypien, Candace; Drummond, Neil; Harasym, Patricia; Nixon, Lara

2015-02-25

Primary care initiatives face an imperative to not only reduce barriers to care for their patients but also to uniquely accommodate the complex needs of at-risk patient populations. Patient-centered multidisciplinary care team models for primary care, like the Alex Seniors Clinic, are one approach for providing comprehensive care for marginalized seniors. The purpose of this qualitative study was to explore patient perspectives on the responsiveness of the Alex Seniors Clinic to their stated health needs. Themes reflected participants' perspectives on factors impacting their health needs as vulnerable seniors as well as on the measures that the Alex Seniors Clinic has taken to meet those needs. Factors impacting health included: the nature of their relationships to the physical environment in which they lived, the nature of the relationships they had to others in that environment, and independence and autonomy. Participants identified accessibility, respect and support, and advocacy as the ways in which the clinic was working to address those health needs. While respect and support, as well as advocacy, effectively addressed some patient needs, participants felt that accessibility problems continue to be health-related barriers for clinic patients. This may be due to the fact that issues of accessibility reflect larger community and social problems. Nevertheless, it is only through engaging the patient community for input on clinic approaches that an understanding can be gained of how closely a clinic's care goals are currently aligning with patient perspectives of the care and services they receive.

A case for the sentence in reading comprehension.

PubMed

Scott, Cheryl M

2009-04-01

This article addresses sentence comprehension as a requirement of reading comprehension within the framework of the narrow view of reading that was advocated in the prologue to this forum. The focus is on the comprehension requirements of complex sentences, which are characteristic of school texts. Topics included in this discussion are (a) evidence linking sentence comprehension and syntax with reading, (b) syntactic properties of sentences that make them difficult to understand, (c) clinical applications for the assessment of sentence comprehension as it relates to reading, and (d) evidence and methods for addressing sentence complexity in treatment. Sentence complexity can create comprehension problems for struggling readers. The contribution of sentence comprehension to successful reading has been overlooked in models that emphasize domain-general comprehension strategies at the text level. The author calls for the evaluation of sentence comprehension within the context of content domains where complex sentences are found.

Navigating complex patients using an innovative tool: the MTM Spider Web.

PubMed

Morello, Candis M; Hirsch, Jan D; Lee, Kelly C

2013-01-01

To introduce a teaching tool that can be used to assess the complexity of medication therapy management (MTM) patients, prioritize appropriate interventions, and design patient-centered care plans for each encounter. MTM patients are complex as a result of multiple comorbidities, medications, and socioeconomic and behavioral issues. Pharmacists who provide MTM services are required to synthesize a plethora of information (medical and nonmedical), evaluate and prioritize the clinical problems, and design a comprehensive patient-centered care plan. The MTM Spider Web is a visual tool to facilitate this process. A description is provided regarding how to build the MTM Spider Web using case-based scenarios. This model can be used to teach pharmacists, health professional students, and patients. The MTM Spider Web is an innovative teaching tool that can be used to teach pharmacists and students how to assess complex patients and design a patient-centered care plan to deliver the most appropriate medication therapy.

Biomaterials and Nanotherapeutics for Enhancing Skin Wound Healing

PubMed Central

Das, Subhamoy; Baker, Aaron B.

2016-01-01

Wound healing is an intricate process that requires complex coordination between many cell types and an appropriate extracellular microenvironment. Chronic wounds often suffer from high protease activity, persistent infection, excess inflammation, and hypoxia. While there has been intense investigation to find new methods to improve cutaneous wound care, the management of chronic wounds, burns, and skin wound infection remain challenging clinical problems. Ideally, advanced wound dressings can provide enhanced healing and bridge the gaps in the healing processes that prevent chronic wounds from healing. These technologies have great potential for improving outcomes in patients with poorly healing wounds but face significant barriers in addressing the heterogeneity and clinical complexity of chronic or severe wounds. Active wound dressings aim to enhance the natural healing process and work to counter many aspects that plague poorly healing wounds, including excessive inflammation, ischemia, scarring, and wound infection. This review paper discusses recent advances in the development of biomaterials and nanoparticle therapeutics to enhance wound healing. In particular, this review focuses on the novel cutaneous wound treatments that have undergone significant preclinical development or are currently used in clinical practice. PMID:27843895

Multiple electrolyte disorders in a neurosurgical patient: solving the rebus

PubMed Central

2013-01-01

Background It is important to ensure an adequate sodium and volume balance in neurosurgical patients in order to avoid the worsening of brain injury. Indeed, hyponatremia and polyuria, that are frequent in this patient population, are potentially harmful, especially if not promptly recognized. Differential diagnosis is often challenging, including disorders, which, in view of similar clinical pictures, present very different pathophysiological bases, such as syndrome of inappropriate antidiuresis, cerebral/renal salt wasting syndrome and diabetes insipidus. Case presentation Here we present the clinical report of a 67-year-old man with a recent episode of acute subarachnoid haemorrhage, admitted to our ward because of severe hyponatremia, hypokalemia and huge polyuria. We performed a complete workup to identify the underlying causes of these alterations and found a complex picture of salt wasting syndrome associated to primary polydipsia. The appropriate diagnosis allowed us to correct the patient hydro-electrolyte balance. Conclusion The comprehension of the pathophysiological mechanisms is essential to adequately recognize and treat hydro-electrolyte disorders, also solving the most complex clinical problems. PMID:23837469

Validation workflow for a clinical Bayesian network model in multidisciplinary decision making in head and neck oncology treatment.

PubMed

Cypko, Mario A; Stoehr, Matthaeus; Kozniewski, Marcin; Druzdzel, Marek J; Dietz, Andreas; Berliner, Leonard; Lemke, Heinz U

2017-11-01

Oncological treatment is being increasingly complex, and therefore, decision making in multidisciplinary teams is becoming the key activity in the clinical pathways. The increased complexity is related to the number and variability of possible treatment decisions that may be relevant to a patient. In this paper, we describe validation of a multidisciplinary cancer treatment decision in the clinical domain of head and neck oncology. Probabilistic graphical models and corresponding inference algorithms, in the form of Bayesian networks, can support complex decision-making processes by providing a mathematically reproducible and transparent advice. The quality of BN-based advice depends on the quality of the model. Therefore, it is vital to validate the model before it is applied in practice. For an example BN subnetwork of laryngeal cancer with 303 variables, we evaluated 66 patient records. To validate the model on this dataset, a validation workflow was applied in combination with quantitative and qualitative analyses. In the subsequent analyses, we observed four sources of imprecise predictions: incorrect data, incomplete patient data, outvoting relevant observations, and incorrect model. Finally, the four problems were solved by modifying the data and the model. The presented validation effort is related to the model complexity. For simpler models, the validation workflow is the same, although it may require fewer validation methods. The validation success is related to the model's well-founded knowledge base. The remaining laryngeal cancer model may disclose additional sources of imprecise predictions.

WE-D-303-00: Computational Phantoms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lewis, John; Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Boston, MA

2015-06-15

Modern medical physics deals with complex problems such as 4D radiation therapy and imaging quality optimization. Such problems involve a large number of radiological parameters, and anatomical and physiological breathing patterns. A major challenge is how to develop, test, evaluate and compare various new imaging and treatment techniques, which often involves testing over a large range of radiological parameters as well as varying patient anatomies and motions. It would be extremely challenging, if not impossible, both ethically and practically, to test every combination of parameters and every task on every type of patient under clinical conditions. Computer-based simulation using computationalmore » phantoms offers a practical technique with which to evaluate, optimize, and compare imaging technologies and methods. Within simulation, the computerized phantom provides a virtual model of the patient’s anatomy and physiology. Imaging data can be generated from it as if it was a live patient using accurate models of the physics of the imaging and treatment process. With sophisticated simulation algorithms, it is possible to perform virtual experiments entirely on the computer. By serving as virtual patients, computational phantoms hold great promise in solving some of the most complex problems in modern medical physics. In this proposed symposium, we will present the history and recent developments of computational phantom models, share experiences in their application to advanced imaging and radiation applications, and discuss their promises and limitations. Learning Objectives: Understand the need and requirements of computational phantoms in medical physics research Discuss the developments and applications of computational phantoms Know the promises and limitations of computational phantoms in solving complex problems.« less

Three-dimensional curvilinear device reconstruction from two fluoroscopic views

NASA Astrophysics Data System (ADS)

Delmas, Charlotte; Berger, Marie-Odile; Kerrien, Erwan; Riddell, Cyril; Trousset, Yves; Anxionnat, René; Bracard, Serge

2015-03-01

In interventional radiology, navigating devices under the sole guidance of fluoroscopic images inside a complex architecture of tortuous and narrow vessels like the cerebral vascular tree is a difficult task. Visualizing the device in 3D could facilitate this navigation. For curvilinear devices such as guide-wires and catheters, a 3D reconstruction may be achieved using two simultaneous fluoroscopic views, as available on a biplane acquisition system. The purpose of this paper is to present a new automatic three-dimensional curve reconstruction method that has the potential to reconstruct complex 3D curves and does not require a perfect segmentation of the endovascular device. Using epipolar geometry, our algorithm translates the point correspondence problem into a segment correspondence problem. Candidate 3D curves can be formed and evaluated independently after identifying all possible combinations of compatible 3D segments. Correspondence is then inherently solved by looking in 3D space for the most coherent curve in terms of continuity and curvature. This problem can be cast into a graph problem where the most coherent curve corresponds to the shortest path of a weighted graph. We present quantitative results of curve reconstructions performed from numerically simulated projections of tortuous 3D curves extracted from cerebral vascular trees affected with brain arteriovenous malformations as well as fluoroscopic image pairs of a guide-wire from both phantom and clinical sets. Our method was able to select the correct 3D segments in 97.5% of simulated cases thus demonstrating its ability to handle complex 3D curves and can deal with imperfect 2D segmentation.

Using a kinesthetic learning strategy to engage nursing student thinking, enhance retention, and improve critical thinking.

PubMed

Wagner, Elissa A

2014-06-01

This article reports the outcomes of a kinesthetic learning strategy used during a cardiac lecture to engage students and to improve the use of classroom-acquired knowledge in today's challenging clinical settings. Nurse educators are constantly faced with finding new ways to engage students, stimulate critical thinking, and improve clinical application in a rapidly changing and complex health care system. Educators who deviate from the traditional pedagogy of didactic, content-driven teaching to a concept-based, student-centered approach using active and kinesthetic learning activities can enhance engagement and improve clinical problem solving, communication skills, and critical thinking to provide graduates with the tools necessary to be successful. The goals of this learning activity were to decrease the well-known classroom-clinical gap by enhancing engagement, providing deeper understanding of cardiac function and disorders, enhancing critical thinking, and improving clinical application. Copyright 2014, SLACK Incorporated.

Testing for EMC (electromagnetic compatibility) in the clinical environment.

PubMed

Paperman, D; David, Y; Martinez, M

1996-01-01

Testing for electromagnetic compatibility (EMC) in the clinical environment introduces a host of complex conditions not normally encountered under laboratory conditions. In the clinical environment, various radio-frequency (RF) sources of electromagnetic interference (EMI) may be present throughout the entire spectrum of interest. Isolating and analyzing the impact from the sources of interference to medical devices involves a multidisciplinary approach based on training in, and knowledge of, the following: operation of medical devices and their susceptibility to EMI; RF propagation modalities and interaction theory; spectrum analysis systems and techniques (preferably with signature analysis capabilities) and calibrated antennas; the investigation methodology of suspected EMC problems, and testing protocols and standards. Using combinations of standard test procedures adapted for the clinical environment with personnel that have an understanding of radio-frequency behavior increases the probability of controlling, proactively, EMI in the clinical environment, thus providing for a safe and more effective patient care environment.

Application of Intervention Mapping to the Development of a Complex Physical Therapist Intervention.

PubMed

Jones, Taryn M; Dear, Blake F; Hush, Julia M; Titov, Nickolai; Dean, Catherine M

2016-12-01

Physical therapist interventions, such as those designed to change physical activity behavior, are often complex and multifaceted. In order to facilitate rigorous evaluation and implementation of these complex interventions into clinical practice, the development process must be comprehensive, systematic, and transparent, with a sound theoretical basis. Intervention Mapping is designed to guide an iterative and problem-focused approach to the development of complex interventions. The purpose of this case report is to demonstrate the application of an Intervention Mapping approach to the development of a complex physical therapist intervention, a remote self-management program aimed at increasing physical activity after acquired brain injury. Intervention Mapping consists of 6 steps to guide the development of complex interventions: (1) needs assessment; (2) identification of outcomes, performance objectives, and change objectives; (3) selection of theory-based intervention methods and practical applications; (4) organization of methods and applications into an intervention program; (5) creation of an implementation plan; and (6) generation of an evaluation plan. The rationale and detailed description of this process are presented using an example of the development of a novel and complex physical therapist intervention, myMoves-a program designed to help individuals with an acquired brain injury to change their physical activity behavior. The Intervention Mapping framework may be useful in the development of complex physical therapist interventions, ensuring the development is comprehensive, systematic, and thorough, with a sound theoretical basis. This process facilitates translation into clinical practice and allows for greater confidence and transparency when the program efficacy is investigated. © 2016 American Physical Therapy Association.

Primer on clinical acid-base problem solving.

PubMed

Whittier, William L; Rutecki, Gregory W

2004-03-01

Acid-base problem solving has been an integral part of medical practice in recent generations. Diseases discovered in the last 30-plus years, for example, Bartter syndrome and Gitelman syndrome, D-lactic acidosis, and bulimia nervosa, can be diagnosed according to characteristic acid-base findings. Accuracy in acid-base problem solving is a direct result of a reproducible, systematic approach to arterial pH, partial pressure of carbon dioxide, bicarbonate concentration, and electrolytes. The 'Rules of Five' is one tool that enables clinicians to determine the cause of simple and complex disorders, even triple acid-base disturbances, with consistency. In addition, other electrolyte abnormalities that accompany acid-base disorders, such as hypokalemia, can be incorporated into algorithms that complement the Rules and contribute to efficient problem solving in a wide variety of diseases. Recently urine electrolytes have also assisted clinicians in further characterizing select disturbances. Acid-base patterns, in many ways, can serve as a 'common diagnostic pathway' shared by all subspecialties in medicine. From infectious disease (eg, lactic acidemia with highly active antiviral therapy therapy) through endocrinology (eg, Conn's syndrome, high urine chloride alkalemia) to the interface between primary care and psychiatry (eg, bulimia nervosa with multiple potential acid-base disturbances), acid-base problem solving is the key to unlocking otherwise unrelated diagnoses. Inasmuch as the Rules are clinical tools, they are applied throughout this monograph to diverse pathologic conditions typical in contemporary practice.

The role (or not) of economic evaluation at the micro level: can Bourdieu's theory provide a way forward for clinical decision-making?

PubMed

Lessard, Chantale; Contandriopoulos, André-Pierre; Beaulieu, Marie-Dominique

2010-06-01

Despite increasing interest in health economic evaluation, investigations have shown limited use by micro (clinical) level decision-makers. A considerable amount of health decisions take place daily at the point of the clinical encounter; especially in primary care. Since every decision has an opportunity cost, ignoring economic information in family physicians' (FPs) decision-making may have a broad impact on health care efficiency. Knowledge translation of economic evaluation is often based on taken-for-granted assumptions about actors' interests and interactions, neglecting much of the complexity of social reality. Health economics literature frequently assumes a rational and linear decision-making process. Clinical decision-making is in fact a complex social, dynamic, multifaceted process, involving relationships and contextual embeddedness. FPs are embedded in complex social networks that have a significant impact on skills, attitudes, knowledge, practices, and on the information being used. Because of their socially constructed nature, understanding preferences, professional culture, practices, and knowledge translation requires serious attention to social reality. There has been little exploration by health economists of whether the problem may be more fundamental and reside in a misunderstanding of the process of decision-making. There is a need to enhance our understanding of the role of economic evaluation in decision-making from a disciplinary perspective different than health economics. This paper argues for a different conceptualization of the role of economic evaluation in FPs' decision-making, and proposes Bourdieu's sociological theory as a research framework. Bourdieu's theory of practice illustrates how the context-sensitive nature of practice must be understood as a socially constituted practical knowledge. The proposed approach could substantially contribute to a more complex understanding of the role of economic evaluation in FPs' decision-making. Copyright 2010 Elsevier Ltd. All rights reserved.

The effects of using concept mapping as an artifact to engender metacognitive thinking in first-year medical students' problem-based learning discussions: A mixed-methods investigation

NASA Astrophysics Data System (ADS)

Shoop, Glenda Hostetter

Attention in medical education is turning toward instruction that not only focuses on knowledge acquisition, but on developing the medical students' clinical problem-solving skills, and their ability to critically think through complex diseases. Metacognition is regarded as an important consideration in how we teach medical students these higher-order, critical thinking skills. This study used a mixed-methods research design to investigate if concept mapping as an artifact may engender metacognitive thinking in the medical student population. Specifically the purpose of the study is twofold: (1) to determine if concept mapping, functioning as an artifact during problem-based learning, improves learning as measured by scores on test questions; and (2) to explore if the process of concept mapping alters the problem-based learning intragroup discussion in ways that show medical students are engaged in metacognitive thinking. The results showed that students in the problem-based learning concept-mapping groups used more metacognitive thinking patterns than those in the problem-based learning discussion-only group, particularly in the monitoring component. These groups also engaged in a higher level of cognitive thinking associated with reasoning through mechanisms-of-action and breaking down complex biochemical and physiologic principals. The students disclosed in focus-group interviews that concept mapping was beneficial to help them understand how discrete pieces of information fit together in a bigger structure of knowledge. They also stated that concept mapping gave them some time to think through these concepts in a larger conceptual framework. There was no significant difference in the exam-question scores between the problem-based learning concept-mapping groups and the problem-based learning discussion-only group.

A systems view of health care for the poor.

PubMed Central

Prasad, N.

1989-01-01

A systems view is a synthesis of health policy, medical sociology, public health, and common clinical problems to describe the current crisis in health care for the poor. Medical sociology and public health are particularly relevant to understand the complexity of clinical issues. Although preventive medicine is in desuetude, it is crucial if we are to reduce the future liability of postponed medical care among the poor. Medicaid metamorphosed to Medicare, as half of its outlays are spent on care of the elderly in nursing homes. Health care for the poor will remain a moral challenge to the architects of health policy and the medical profession. PMID:2659807

Insights on adaptive and innate immunity in canine leishmaniosis.

PubMed

Hosein, Shazia; Blake, Damer P; Solano-Gallego, Laia

2017-01-01

Canine leishmaniosis (CanL) is caused by the parasite Leishmania infantum and is a systemic disease, which can present with variable clinical signs, and clinicopathological abnormalities. Clinical manifestations can range from subclinical infection to very severe systemic disease. Leishmaniosis is categorized as a neglected tropical disease and the complex immune responses associated with Leishmania species makes therapeutic treatments and vaccine development challenging for both dogs and humans. In this review, we summarize innate and adaptive immune responses associated with L. infantum infection in dogs, and we discuss the problems associated with the disease as well as potential solutions and the future direction of required research to help control the parasite.

Modern Endodontic Principles Part 4: Irrigation.

PubMed

Darcey, James; Jawad, Sarra; Taylor, Carly; Roudsari, Reza Vahid; Hunter, Mark

2016-01-01

The complex anatomy of the tooth limits the ability to eradicate pathogens by mechanical means alone. Irrigation is the key to solving this problem. This paper highlights the importance of irrigation, the key irrigants available and methods of improving the performance of irrigants within the canal. CPD/CLINICAL RELEVANCE: To provide advice on which irrigants to use, how to use them effectively and safely and what to do if irrigants are extruded beyond the apex.

Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey.

PubMed

Fumagalli, Stefano; Potpara, Tatjana S; Bjerregaard Larsen, Torben; Haugaa, Kristina H; Dobreanu, Dan; Proclemer, Alessandro; Dagres, Nikolaos

2017-11-01

The age of patients presenting with complex arrhythmias is increasing. Frailty is a multifaceted syndrome characterized by an increased vulnerability to stressors and a decreased ability to maintain homeostasis. The prevalence of frailty is associated with age. The aims of this European Heart Rhythm Association (EHRA) EP Wire survey were to evaluate the proportion of patients with frailty and its influence on the clinical management of arrhythmias. A total of 41 centres-members of the EHRA Electrophysiology Research Network-in 14 European countries completed the web-based questionnaire in June 2017. Patients over 70 years represented 53% of the total treated population, with the proportion of frail elderly individuals reaching approximately 10%; 91.7% of the responding centres reported treating frail subjects in the previous year. The respondents usually recognized frailty based on the presence of problems of mobility, nutrition, and cognition and inappropriate loss of body weight and muscle mass. Renal failure, dementia, disability, atrial fibrillation, heart failure, falls, and cancer were reported to characterize the elderly frail individuals. Atrial fibrillation was considered the prevalent arrhythmia associated with frailty by 72% of the responding centres, and for stroke prevention, non-vitamin K antagonist oral anticoagulants were preferred. None of the respondents considered withholding the prevention of thrombo-embolic events in subjects with a history of falls. All participants have agreed that cardiac resynchronization therapy exerts positive effects including improvement in cardiac, physical, and cognitive performance and quality of life. The majority of respondents preferred an Arrhythmia Team to manage this special population of elderly patients, and many would like having a simple tool to quickly assess the presence of frailty to guide their decisions, particularly on the use of complex cardiac implantable electrical devices (CIEDs). In conclusion, the complex clinical condition in frail patients presenting with arrhythmias warrants an integrated multidisciplinary approach both for the management of rhythm disturbances and for the decision on using CIEDs. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

MRI Segmentation of the Human Brain: Challenges, Methods, and Applications

PubMed Central

Despotović, Ivana

2015-01-01

Image segmentation is one of the most important tasks in medical image analysis and is often the first and the most critical step in many clinical applications. In brain MRI analysis, image segmentation is commonly used for measuring and visualizing the brain's anatomical structures, for analyzing brain changes, for delineating pathological regions, and for surgical planning and image-guided interventions. In the last few decades, various segmentation techniques of different accuracy and degree of complexity have been developed and reported in the literature. In this paper we review the most popular methods commonly used for brain MRI segmentation. We highlight differences between them and discuss their capabilities, advantages, and limitations. To address the complexity and challenges of the brain MRI segmentation problem, we first introduce the basic concepts of image segmentation. Then, we explain different MRI preprocessing steps including image registration, bias field correction, and removal of nonbrain tissue. Finally, after reviewing different brain MRI segmentation methods, we discuss the validation problem in brain MRI segmentation. PMID:25945121

Ethical challenges in conducting clinical research in lung cancer

PubMed Central

Tod, Angela M.

2016-01-01

The article examines ethical challenges that arise with clinical lung cancer research focusing on design, recruitment, conduct and dissemination. Design: problems related to equipoise can arise in lung cancer studies. Equipoise is an ethics precondition for RCTs and exists where there is insufficient evidence to decide which of two or more treatments is best. Difficulties arise in deciding what level of uncertainty constitutes equipoise and who should be in equipoise, for example, patients might not be even where clinicians are. Patient and public involvement (PPI) can reduce but not remove the problems. Recruitment: (I) lung cancer studies can be complex, making it difficult to obtain good quality consent. Some techniques can help, such as continuous consent. But researchers should not expect consent to be the sole protection for participants’ welfare. This protection is primarily done elsewhere in the research process, for example, in ethics review; (II) the problem of desperate volunteers: some patients only consent to a trial because it gives them a 50/50 option of the treatment they want and can be disappointed or upset if randomised to the other arm. This is not necessarily unfair, given clinical equipoise. However, it should be avoided where possible, for example, by using alternative trial designs; (III) the so-called problem of therapeutic misconception: this is the idea that patients are mistaken if they enter trials believing this to be in their clinical best interest. We argue the problem is misconceived and relates only to certain health systems. Conduct: lung cancer trials face standard ethical challenges with regard to trial conduct. PPI could be used in decisions about criteria for stopping rules. Dissemination: as in other trial areas, it is important that all results, including negative ones, are reported. We argue also that the role of PPI with regard to dissemination is currently under-developed. PMID:27413698

Behavioral and cognitive outcomes for clinical trials in children with neurofibromatosis type 1.

PubMed

van der Vaart, Thijs; Rietman, André B; Plasschaert, Ellen; Legius, Eric; Elgersma, Ype; Moll, Henriëtte A

2016-01-12

To evaluate the appropriateness of cognitive and behavioral outcome measures in clinical trials in neurofibromatosis type 1 (NF1) by analyzing the degree of deficits compared to reference groups, test-retest reliability, and how scores correlate between outcome measures. Data were analyzed from the Simvastatin for cognitive deficits and behavioral problems in patients with neurofibromatosis type 1 (NF1-SIMCODA) trial, a randomized placebo-controlled trial of simvastatin for cognitive deficits and behavioral problems in children with NF1. Outcome measures were compared with age-specific reference groups to identify domains of dysfunction. Pearson r was computed for before and after measurements within the placebo group to assess test-retest reliability. Principal component analysis was used to identify the internal structure in the outcome data. Strongest mean score deviations from the reference groups were observed for full-scale intelligence (-1.1 SD), Rey Complex Figure Test delayed recall (-2.0 SD), attention problems (-1.2 SD), and social problems (-1.1 SD). Long-term test-retest reliability were excellent for Wechsler scales (r > 0.88), but poor to moderate for other neuropsychological tests (r range 0.52-0.81) and Child Behavioral Checklist subscales (r range 0.40-0.79). The correlation structure revealed 2 strong components in the outcome measures behavior and cognition, with no correlation between these components. Scores on psychosocial quality of life correlate strongly with behavioral problems and less with cognitive deficits. Children with NF1 show distinct deficits in multiple domains. Many outcome measures showed weak test-retest correlations over the 1-year trial period. Cognitive and behavioral outcomes are complementary. This analysis demonstrates the need to include reliable outcome measures on a variety of cognitive and behavioral domains in clinical trials for NF1. © 2015 American Academy of Neurology.

Solving Complex Problems: A Convergent Approach to Cognitive Load Measurement

ERIC Educational Resources Information Center

Zheng, Robert; Cook, Anne

2012-01-01

The study challenged the current practices in cognitive load measurement involving complex problem solving by manipulating the presence of pictures in multiple rule-based problem-solving situations and examining the cognitive load resulting from both off-line and online measures associated with complex problem solving. Forty-eight participants…

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication.

PubMed

Bergman, Alicia A; Jaynes, Heather A; Gonzalvo, Jasmine D; Hudmon, Karen Suchanek; Frankel, Richard M; Kobylinski, Amanda L; Zillich, Alan J

2016-01-01

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist-PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist-PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists' indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.

Clinical-decision support based on medical literature: A complex network approach

NASA Astrophysics Data System (ADS)

Jiang, Jingchi; Zheng, Jichuan; Zhao, Chao; Su, Jia; Guan, Yi; Yu, Qiubin

2016-10-01

In making clinical decisions, clinicians often review medical literature to ensure the reliability of diagnosis, test, and treatment because the medical literature can answer clinical questions and assist clinicians making clinical decisions. Therefore, finding the appropriate literature is a critical problem for clinical-decision support (CDS). First, the present study employs search engines to retrieve relevant literature about patient records. However, the result of the traditional method is usually unsatisfactory. To improve the relevance of the retrieval result, a medical literature network (MLN) based on these retrieved papers is constructed. Then, we show that this MLN has small-world and scale-free properties of a complex network. According to the structural characteristics of the MLN, we adopt two methods to further identify the potential relevant literature in addition to the retrieved literature. By integrating these potential papers into the MLN, a more comprehensive MLN is built to answer the question of actual patient records. Furthermore, we propose a re-ranking model to sort all papers by relevance. We experimentally find that the re-ranking model can improve the normalized discounted cumulative gain of the results. As participants of the Text Retrieval Conference 2015, our clinical-decision method based on the MLN also yields higher scores than the medians in most topics and achieves the best scores for topics: #11 and #12. These research results indicate that our study can be used to effectively assist clinicians in making clinical decisions, and the MLN can facilitate the investigation of CDS.

Clinical challenges of chronic wounds: searching for an optimal animal model to recapitulate their complexity

PubMed Central

Nunan, Robert; Harding, Keith G.; Martin, Paul

2014-01-01

The efficient healing of a skin wound is something that most of us take for granted but is essential for surviving day-to-day knocks and cuts, and is absolutely relied on clinically whenever a patient receives surgical intervention. However, the management of a chronic wound – defined as a barrier defect that has not healed in 3 months – has become a major therapeutic challenge throughout the Western world, and it is a problem that will only escalate with the increasing incidence of conditions that impede wound healing, such as diabetes, obesity and vascular disorders. Despite being clinically and molecularly heterogeneous, all chronic wounds are generally assigned to one of three major clinical categories: leg ulcers, diabetic foot ulcers or pressure ulcers. Although we have gleaned much knowledge about the fundamental cellular and molecular mechanisms that underpin healthy, acute wound healing from various animal models, we have learned much less about chronic wound repair pathology from these models. This might largely be because the animal models being used in this field of research have failed to recapitulate the clinical features of chronic wounds. In this Clinical Puzzle article, we discuss the clinical complexity of chronic wounds and describe the best currently available models for investigating chronic wound pathology. We also assess how such models could be optimised to become more useful tools for uncovering pathological mechanisms and potential therapeutic treatments. PMID:25359790

Under-treatment of type 2 diabetes: Causes and outcomes of clinical inertia.

PubMed

Bailey, Clifford J

2016-12-01

To assess the impact of clinical inertia on type 2 diabetes (T2D) care. PubMed database search from January 2000 until December 2015. Clinical inertia, defined as resistance to initiate or intensify treatment in a patient not at the evidence-based glycated haemoglobin goal, is conservatively estimated to occur in at least 25% of patients with T2D. Consequently, many patients with diagnosed and treated T2D experience extended periods, in some cases years, of ineffectively controlled hyperglycaemia, potentially causing serious microvascular and macrovascular harm. Delayed treatment does not appear to be specific to primary care, but also occurs in the specialist setting. The causes of clinical inertia appear to be complex, involving both reasonable and unacceptable delays on the part of the clinician and poor compliance with treatment regimens on the part of the patient. Evidence suggests that the clinical and organisational context may be particularly important in reinforcing clinical inertia, notably the increasingly severe time constraints for diagnosis and management of multiple morbidities, consideration of complex guidelines, assessment of cost and appreciation of patient concerns, all of which may hamper prioritisation of the important issue of under-treatment. Since the pharmacotherapeutic tools for good control of blood glucose exist in all advanced healthcare systems, initiatives to address the important and widespread problem of clinical inertia may require focused campaigns that encourage attention to guideline recommendations and their adaptation for individualised care. © 2016 John Wiley & Sons Ltd.

Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting.

PubMed

Clarke, Christina M; Persaud, Drepaul David

2011-03-01

Many contemporary acute care facilities lack safe and effective clinical handover practices resulting in patient transitions that are vulnerable to discontinuities in care, medical errors, and adverse patient safety events. This article is intended to supplement existing handover improvement literature by providing practical guidance for leaders and managers who are seeking to improve the safety and the effectiveness of clinical handovers in the acute care setting. A 4-stage change model has been applied to guide the application of strategies for handover improvement. Change management and quality improvement principles, as well as concepts drawn from safety science and high-reliability organizations, were applied to inform strategies. A model for handover improvement respecting handover complexity is presented. Strategies targeted to stages of change include the following: 1. Enhancing awareness of handover problems and opportunities with the support of strategic directions, accountability, end user involvement, and problem complexity recognition. 2. Identifying solutions by applying and adapting best practices in local contexts. 3. Implementing locally adapted best practices supported by communication, documentation, and training. 4. Institutionalizing practice changes through integration, monitoring, and active dissemination. Finally, continued evaluation at every stage is essential. Although gaps in handover process and function knowledge remain, efforts to improve handover safety and effectiveness are still possible. Continued evaluation is critical in building this understanding and to ensure that practice changes lead to improvements in patient safety, organizational effectiveness, and patient and provider satisfaction. Through handover knowledge building, fundamental changes in handover policies and practices may be possible.

[Critical reflections concerning euthanasia for persons with dementia].

PubMed

De Lepeleire, J; Beyen, A; Burin, M; Fabri, R; Ghijsebrechts, G; Lisaerde, J; Temmerman, B; Van den Eynden, B; Van den Noortgate, N

2010-01-01

In the public debate on the extension of euthanasia for people with dementia, in addition to ethical considerations and arguments, other issues have to be kept in mind. The diagnosis of dementia is difficult and the clinical picture is very fluctuating. The assessment and especially the operationalization of legal capacity and the use of advance directives are complex problems. The discussion should be conducted against the backdrop of a cultural framework in which the interpretation and development of palliative care is crucial. The development of a framework like advance care planning creates opportunities. The question remains whether the legal issues can be clarified and whether a legal approach generates solutions for the problems described.

Euthanasia from the perspective of hospice care.

PubMed

Gillett, G

1994-01-01

The hospice believes in the concept of a gentle and harmonious death. In most hospice settings there is also a rejection of active euthanasia. This set of two apparently conflicting principles can be defended on the basis of two arguments. The first is that doctors should not foster the intent to kill as part of their moral and clinical character. This allows proper sensitivity to the complex and difficult situation that arises in many of the most difficult terminal care situations. The second argument turns on the seduction of technological solutions to human problems and the slippery slope that may arise in the presence of a quick and convenient way of dealing with problems of death and dying.

[A way of helping "Mr. Minotaur" and "Ms. Ariadne" to exit from the multiple morbidity labyrinth: the "master problems"].

PubMed

Turabián, J L; Pérez Franco, B

2016-01-01

Multiple morbidity seems to be "infinite" and so is not easy to make useful decisions. A new concept is introduced: the "master problems", as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These "master problems" generally remain hidden and can only "unravel" between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with "energy" or a "master problem" is complex, multiple and dramatic or theatrical--everything in the clinical history history make us look into that particular question. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high "density of emotions", human elements, social symbols, and opens solutions in a patient. Copyright © 2015 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.

How to write a critically appraised topic (CAT).

PubMed

Sadigh, Gelareh; Parker, Robert; Kelly, Aine Marie; Cronin, Paul

2012-07-01

Medical knowledge and the volume of scientific articles published have expanded rapidly over the past 50 years. Evidence-based practice (EBP) has developed to help health practitioners get more benefit from the increasing volume of information to solve complex health problems. A format for sharing information in EBP is the critically appraised topic (CAT). A CAT is a standardized summary of research evidence organized around a clinical question, aimed at providing both a critique of the research and a statement of the clinical relevance of results. In this review, we explain the five steps involved in writing a CAT for a clinical purpose ("Ask," "Search," "Appraise," "Apply," and "Evaluate") and introduce some of the useful electronic resources available to help in creating CATs. Copyright © 2012 AUR. Published by Elsevier Inc. All rights reserved.

Platinum, palladium, gold and ruthenium complexes as anticancer agents: Current clinical uses, cytotoxicity studies and future perspectives.

PubMed

Lazarević, Tatjana; Rilak, Ana; Bugarčić, Živadin D

2017-12-15

Metallodrugs offer potential for unique mechanism of drug action based on the choice of the metal, its oxidation state, the types and number of coordinated ligands and the coordination geometry. This review illustrates notable recent progress in the field of medicinal bioinorganic chemistry as many new approaches to the design of innovative metal-based anticancer drugs are emerging. Current research addressing the problems associated with platinum drugs has focused on other metal-based therapeutics that have different modes of action and on prodrug and targeting strategies in an effort to diminish the side-effects of cisplatin chemotherapy. Examples of metal compounds and chelating agents currently in clinical use, clinical trials or preclinical development are highlighted. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Therapeutic antibodies against cancer

PubMed Central

Adler, Mark J.; Dimitrov, Dimiter S.

2012-01-01

Antibody-based therapeutics against cancer are highly successful in clinic and currently enjoy unprecedented recognition of their potential; 13 monoclonal antibodies (mAbs) have been approved for clinical use in the European Union and in the United States (one, mylotarg, was withdrawn from market in 2010). Three of the mAbs (bevacizumab, rituximab, trastuzumab) are in the top six selling protein therapeutics with sales in 2010 of more than $5 bln each. Hundreds of mAbs including bispecific mAbs and multispecific fusion proteins, mAbs conjugated with small molecule drugs and mAbs with optimized pharmacokinetics are in clinical trials. However, challenges remain and it appears that deeper understanding of mechanisms is needed to overcome major problems including resistance to therapy, access to targets, complexity of biological systems and individual variations. PMID:22520975

Perspective: Simulation and transformational change: the paradox of expertise.

PubMed

Kneebone, Roger

2009-07-01

Simulation is widely seen as a space where procedural skills can be practiced in safety, free from the pressures and complexities of clinical care. Central to this approach is the notion of simplification, a stripping down of skills into their component parts. Yet the definition of simplicity is contestable, often determined by experts without reference to those they teach.The author uses the ha-ha, a hidden ditch around a large country house used by 18th-century English landscape gardeners to create an illusion that the house is surrounded by untamed nature, as a metaphor for the differing perspectives of expert and novice. The author proposes that this difference of perspective lies at the heart of many current problems with simulation and simulators.This article challenges the philosophy of simplification, arguing that procedural skills should not be divorced from their clinical context and that oversimplification of a complex process can interfere with deep understanding. The author draws on Meyer and Land's notions of threshold concepts and troublesome knowledge and on his own experience with patient-focused simulation to propose an alternative view of simulation, framing it as a safe space which can reflect the uncertainties of clinical practice and recreate the conditions of real-world learning. By reintroducing complexity and human unpredictability, simulation can provide a safe environment for assisting the transformational change that is essential to becoming a competent clinician.

Improving the quality of palliative care for ambulatory patients with lung cancer

PubMed Central

von Plessen, Christian; Aslaksen, Aslak

2005-01-01

Problem Most patients with advanced lung cancer currently receive much of their health care, including chemotherapy, as outpatients. Patients have to deal with the complex and time consuming logistics of ambulatory cancer care. At the same time, members of staff often waste considerable time and energy in organisational aspects of care that could be better used in direct interaction with patients. Design Quality improvement study using direct observation and run and flow charts, and focus group meetings with patients and families regarding perceptions of the clinic and with staff regarding satisfaction with working conditions. Setting Thoracic oncology outpatient clinic at a Norwegian university hospital where patients receive chemotherapy and complementary palliative care. Key measures for improvement Waiting time and time wasted during consultations; calmer working situation at the clinic; satisfaction among patients. Strategies for change Rescheduled patients' appointments, automated retrieval of blood test results, systematic reporting in patients' files, design of an information leaflet, and refurnishing of the waiting area at the clinic. Effects of change Interventions resulted in increased satisfaction for patients and staff, reduced waiting time, and reduced variability of waiting time. Lessons learnt Direct observation, focus groups, questionnaires on patients' satisfaction, and measurement of process time were useful in systematically improving care in this outpatient clinic. The description of this experience can serve as an example for the improvement of a microsystem, particularly in other settings with similar problems. PMID:15933354

Differential diagnosis of hyperkalemia: an update to a complex problem.

PubMed

Eleftheriadis, T; Leivaditis, K; Antoniadi, G; Liakopoulos, V

2012-10-01

Hyperkalemia is a relative common and sometimes life threatening electorlyte disorder. Although its symptomatic treatment is relatively easy, since precise therapeutic algorithms are available, its differential diagnosis is more complicated. The present review aims to unfold the differential diagnosis of hypekalemia using a pathophysiological, albeit clinically useful, approach. The basic elements of potassium homeostasis are provided, the causes of hyperkalemia are categorized and analysed and finally the required for the diferrential diagnosis laboratory tests are mentioned.

[Bad breath--etiological, diagnostic and therapeutic problems].

PubMed

Reiss, M; Reiss, G

2000-01-01

Oral malodor has many etiologies and is a clinical problem for many people. This paper reviews the causes and management of oral malador. In the majority of cases the problem has been shown to originate in the oral cavity. Oral malodor, a generic descriptor term for foul smells emanating from the mouth, encompasses ozostomia, stomatodysodia, halitosis (both pathological halitosis and physiological halitosis) and fetor oris or fetor ex ore. These latter terms, in turn, denote different sources of oral malodor. All conditions that favour the retention of anaerobic, mainly gram-negative, bacteria will predispose for the development of bad breath. In addition to periodontal pockets, the most important retention site is the dorsum of the tongue with its numerous papillae. During the night and between meals the conditions are optimal for odour production. Systemic pathological states, such as diabetes mellitus, uremia and hepatic diseases, induce metabolic products that are detectable as oral smells. It is always easy to recognize halitosis, but identifying the exact cause is more complex. The clinical labelling and interpretation of different oral malodors both contribute to the diagnosis and treatment of underlying disease. Treatment is directed at the underlying cause.

The prevalence and spectrum of sleep problems in women with transformed migraine.

PubMed

Calhoun, Anne H; Ford, Sutapa; Finkel, Alan G; Kahn, Kevin A; Mann, J Douglas

2006-04-01

It is our clinical observation that patients with transformed migraine (TM) almost invariably report nonrestorative sleep. In this study we sought first to validate that clinical observation, then to describe the prevalence and spectrum of factors that might contribute to nonrestorative sleep in a TM population. Although headaches have been linked with sleep problems for over a century, there is little information about the spectrum or prevalence of specific sleep problems associated with TM in adults. We conducted a detailed sleep interview on 147 consecutive women with TM. Subjective sleep quality was assessed by asking patients to describe their state upon awakening as "refreshed" or "tired." None of the 147 patients reported awakening "refreshed," and 83.7% stated that they awakened "tired." Sleep complaints were prevalent and varied in this population. Although the relationship between pain and sleep is complex and ill understood, we found a very high prevalence of nonrestorative sleep and a similarly high prevalence of modifiable poor sleep habits in patients with TM. Since behavioral approaches have been found effective in improving sleep quality in patients with poor sleep hygiene, we propose that studies be undertaken to assess the impact of such treatment on TM.

Learning challenges of nursing students in clinical environments: A qualitative study in Iran

PubMed Central

Baraz, Shahram; Memarian, Robabeh; Vanaki, Zohreh

2015-01-01

Background: Clinical learning environment is a complex social entity. This environment is effective on the learning process of nursing students in the clinical area. However, learning in clinical environment has several benefits, but it can be challenging, unpredictable, stressful, and constantly changing. In attention to clinical experiences and factors contributing to the learning of these experiences can waste a great deal of time and energy, impose heavy financial burden on educational systems, cause mental, familial and educational problems for students, and compromise the quality of patient care. Therefore, this study was carried out with the goal of determining the learning challenges of nursing students in clinical environments in Iran. Materials and Methods: In this qualitative study carried out in 2012–2013, 18 undergraduate nursing students were selected by using purposive sampling method from the Faculty of Nursing and Midwifery of Tehran and Shahid Beheshti Universities. Semi-structured interviews were used to collect data. The content analysis method was used to determine relevant themes. Results: Two themes were derived from the data analysis, which represented the students’ clinical learning challenges. These two themes included insufficient qualification of nursing instructors and unsupportive learning environment. Conclusions: Identification of the students’ clinical learning challenges and actions to remove or modify them will create more learning opportunities for the students, improve the achievement of educational goals, provide training to nursing students with the needed competencies to meet the complex demands of caring and for application of theories in practice, and improve the quality of healthcare services. PMID:26430679

Clinical profile of STD clinic patients seropositive for HIV antibodies.

PubMed

Krishnaiah, Y R; Babu, V S; Lakshmi, N; Kumar, A G

1989-01-01

This article provides clinical profiles for HIV seropositive patients discovered at an STD clinic in Tirupati, India. Considering that sexual contact is the most common mode of transmission of HIV, researchers from the SV Medical College at Tirupati conducted a surveillance for HIV infection among patients attending an STD clinic. From January 1988 to April 1989, the researchers collected serum samples from 2320 patients. 11 people were found to be infected with HIV, 1 of whom exhibited the AIDS Related Complex (ARC). 9 out the HIV-infected patients were 20-30 year-old males categorized as heterosexually promiscuous; the remaining 2 seropositive patients were female prostitutes. The seropositivity rate among heterosexually promiscuous males was 0.58%, and 6.7% among female prostitutes (the total seropositivity rate was 0.47%). Among the HIV-infected patients, the most commonly associated STD was syphilis. 5 of the patients had syphilis alone, and 2 others had syphilis and another STD. One of the HIV-infected patients, a 50 year-old heterosexual male with a history of multiple partners, suffered from a nonhealing genital ulcer and inguinal buboes of 1 month duration. A biopsy of the genital ulcer revealed a pattern consistent with that of granuloma venereum. He also developed angular stomatitis which did not respond to B complex therapy. Furthermore, suffering from persistent lymphadenopathy, weight loss, slight thrombo-cytopenia, an opportunistic infection in the form of oral candidosis and persistent seropositivity for HIV antibodies, the patient was deemed to have the AIDS Related Complex. Tirupati's seropositivity rate of .47% was higher that noticed in other parts of the country, leading the authors call for a plan to investigate the problems of HIV-infected people.

The determination factors of left-right asymmetry disorders- a short review.

PubMed

Catana, Andreea; Apostu, Adina Patricia

2017-01-01

Laterality defects in humans, situs inversus and heterotaxy, are rare disorders, with an incidence of 1:8000 to 1:10 000 in the general population, and a multifactorial etiology. It has been proved that 1.44/10 000 of all cardiac problems are associated with malformations of left-right asymmetry and heterotaxy accounts for 3% of all congenital heart defects. It is considered that defects of situs appear due to genetic and environmental factors. Also, there is evidence that the ciliopathies (defects of structure or function) are involved in development abnormalities. Over 100 genes have been reported to be involved in left-right patterning in model organisms, but only a few are likely to candidate for left-right asymmetry defects in humans. Left-right asymmetry disorders are genetically heterogeneous and have variable manifestations (from asymptomatic to serious clinical problems). The discovery of the right mechanism of left-right development will help explain the clinical complexity and may contribute to a therapy of these disorders.

Performance of uncertainty quantification methodologies and linear solvers in cardiovascular simulations

NASA Astrophysics Data System (ADS)

Seo, Jongmin; Schiavazzi, Daniele; Marsden, Alison

2017-11-01

Cardiovascular simulations are increasingly used in clinical decision making, surgical planning, and disease diagnostics. Patient-specific modeling and simulation typically proceeds through a pipeline from anatomic model construction using medical image data to blood flow simulation and analysis. To provide confidence intervals on simulation predictions, we use an uncertainty quantification (UQ) framework to analyze the effects of numerous uncertainties that stem from clinical data acquisition, modeling, material properties, and boundary condition selection. However, UQ poses a computational challenge requiring multiple evaluations of the Navier-Stokes equations in complex 3-D models. To achieve efficiency in UQ problems with many function evaluations, we implement and compare a range of iterative linear solver and preconditioning techniques in our flow solver. We then discuss applications to patient-specific cardiovascular simulation and how the problem/boundary condition formulation in the solver affects the selection of the most efficient linear solver. Finally, we discuss performance improvements in the context of uncertainty propagation. Support from National Institute of Health (R01 EB018302) is greatly appreciated.

[From the Principle of Beneficence to the Principle of Autonomy. Assessment of Patients' Mental Competency in the General Hospital].

PubMed

Diana, Restrepo B; Carlos, Cardeño C; Marle, Duque G; Santiago, Jaramillo

2012-06-01

Refusing a medical procedure is a valid way of exercising every patient's right to autonomy. From the legal point of view, autonomy is based on the right to privacy. In recent decades the legal right to self-determination has gradually expanded and today patients in full possession of their mental faculties, have the moral and legal right to make their own decisions and these decisions take precedence over physician and family. Often liaison psychiatrists are called in to assess the mental competence of patients in the general hospital. To determine the psychiatrist's role in evaluating these patients. The assessment of a patient's ability to decide and self-determine is a common clinical problem in general hospitals. Evaluation of these patients requires a proper understanding of the philosophical, ethical, and legal issues that guide the appropriate treatment of these complex clinical problems. Copyright © 2012 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España. All rights reserved.

The guiltless guilty: trauma-related guilt and psychopathology in former Ugandan child soldiers.

PubMed

Klasen, Fionna; Reissmann, Sina; Voss, Catharina; Okello, James

2015-04-01

Child soldiers often experience complex trauma as victims and perpetrators, and feelings of guilt may affect their psychological health. The relationship between the children's traumatic experiences as victims or perpetrators, their perception of themselves as victim or perpetrator, guilt and psychopathology were investigated: of the 330 former child soldiers interviewed, 50.8 % perceived themselves as victims and 19.1 % as perpetrators. On psychopathology measures, scores within the clinical range were 33 % for posttraumatic stress disorder (PTSD), 36.4 % for major depressive disorder (MDD), and 26.1 % for externalizing problems. Low socio-economic status, traumatic experience as perpetrator, and guilt were significant predictors of PTSD. Significant predictors of MDD were low socio-economic status, traumatic experiences as victim, and guilt. A greater number of traumatic experiences as perpetrator and guilt were associated with externalizing problems. The current paper underscores the significance of guilt following traumatic experiences and has implications for the development of clinical interventions for war-affected children.

Sexual Harassment: A Concern for the Athletic Trainer

PubMed Central

Velasquez, Benito J.

1998-01-01

Objective: Sexual harassment is a vital social issue that affects the business community, educational institutions, and personnel in the U.S. military. Addressing sexual harassment in the athletic training clinical setting is an important issue for the athletic training professional. Athletic trainers need to understand the complex definitions of sexual harassment and how to identify and handle claims of sexual harassment in order to prevent sexual harassment from occurring and to prevent civil lawsuits of alleged sexual harassment. Background: Professional journals, legal textbooks, policy handbooks, unpublished findings from the NATA Women in Athletic Training Committee report, and current news media sources were used to gain a greater understanding of this social problem. Description: To make the athletic trainer aware of this important social issue and to offer suggestions for the athletic training staff to aid in preventing problems of sexual harassment. Clinical Advantages: This article provides definitions and examples of sexual harassment, discussion of policy development, and suggestions for ways to eliminate sexual harassment in the athletic training environment. PMID:16558507

Iraq and Afghanistan Veterans: National Findings from VA Residential Treatment Programs

PubMed Central

Cook, Joan M.; Dinnen, Stephanie; O’Donnell, Casey; Bernardy, Nancy; Rosenheck, Robert; Desai, Rani

2013-01-01

A quality improvement effort was undertaken in Department of Veterans Affairs’ (VA) residential treatment programs for Posttraumatic Stress Disorder (PTSD) across the United States. Qualitative interviews were conducted with over 250 directors, providers, and staff during site visits of 38 programs. The aims of this report are to describe clinical issues and distinctive challenges in working with veterans from Iraq and Afghanistan and approaches to addressing their needs. Providers indicated that the most commonly reported problems were: acute PTSD symptomotology; other complex mental health symptom presentations; broad readjustment problems; and difficulty with time demands of and readiness for intensive treatment. Additional concerns included working with active duty personnel and mixing different eras in therapy. Programmatic solutions address structure (e.g., blended versus era-specific therapy), content (e.g., physical activity), and adaptations (e.g., inclusion of family; shortened length of stay). Clinical implications for VA managers and policy makers as well as non-VA health care systems and individual health care providers are noted. PMID:23458113

Severe complications in wound healing and fracture treatment in two brothers with congenital insensitivity to pain with anhidrosis.

PubMed

Rapp, Marion; Spiegler, Juliane; Härtel, Christoph; Gillessen-Kaesbach, Gabrielle; Kaiser, Martin M

2013-01-01

Congenital insensitivity to pain with anhidrosis is an autosomal recessive disorder caused by mutations in the neurotrophic tyrosine receptor kinase 1 (NTRK1) gene, which encodes the receptor for nerve growth factor. We report the clinical and radiological pitfalls in the diagnosis and treatment of two brothers, aged 5 and 8 years, with congenital insensitivity to pain with anhidrosis, the older brother having a proven NTRK1 mutation. In the neonatal period, both presented with recurrent episodes of fever of unknown origin, but their clinical problems changed later. In addition to severe mental retardation and self-harming behaviour, the older brother developed recurrent nonbacterial destructive infections of both the calcaneus and later the talus. No immunodeficiency was found. The younger brother had three complex fractures with a long history of healing problems: overwhelming production of callus, osteomyelitis and movement restrictions. He has less mental retardation than his older brother and shows no self-mutilation.

Challenges in translating vascular tissue engineering to the pediatric clinic.

PubMed

Duncan, Daniel R; Breuer, Christopher K

2011-10-14

The development of tissue-engineered vascular grafts for use in cardiovascular surgery holds great promise for improving outcomes in pediatric patients with complex congenital cardiac anomalies. Currently used synthetic grafts have a number of shortcomings in this setting but a tissue engineering approach has emerged in the past decade as a way to address these limitations. The first clinical trial of this technology showed that it is safe and effective but the primary mode of graft failure is stenosis. A variety of murine and large animal models have been developed to study and improve tissue engineering approaches with the hope of translating this technology into routine clinical use, but challenges remain. The purpose of this report is to address the clinical problem and review recent advances in vascular tissue engineering for pediatric applications. A deeper understanding of the mechanisms of neovessel formation and stenosis will enable rational design of improved tissue-engineered vascular grafts.

Service quality and clinical outcomes: an example from mental health rehabilitation services in England.

PubMed

Killaspy, Helen; Marston, Louise; Omar, Rumana Z; Green, Nicholas; Harrison, Isobel; Lean, Melanie; Holloway, Frank; Craig, Tom; Leavey, Gerard; King, Michael

2013-01-01

Current health policy assumes better quality services lead to better outcomes. To investigate the relationship between quality of mental health rehabilitation services in England, local deprivation, service user characteristics and clinical outcomes. Standardised tools were used to assess the quality of mental health rehabilitation units and service users' autonomy, quality of life, experiences of care and ratings of the therapeutic milieu. Multiple level modelling investigated relationships between service quality, service user characteristics and outcomes. A total of 52/60 (87%) National Health Service trusts participated, comprising 133 units and 739 service users. All aspects of service quality were positively associated with service users' autonomy, experiences of care and therapeutic milieu, but there was no association with quality of life. Quality of care is linked to better clinical outcomes in people with complex and longer-term mental health problems. Thus, investing in quality is likely to show real clinical gains.

WE-D-303-01: Development and Application of Digital Human Phantoms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Segars, P.

2015-06-15

Modern medical physics deals with complex problems such as 4D radiation therapy and imaging quality optimization. Such problems involve a large number of radiological parameters, and anatomical and physiological breathing patterns. A major challenge is how to develop, test, evaluate and compare various new imaging and treatment techniques, which often involves testing over a large range of radiological parameters as well as varying patient anatomies and motions. It would be extremely challenging, if not impossible, both ethically and practically, to test every combination of parameters and every task on every type of patient under clinical conditions. Computer-based simulation using computationalmore » phantoms offers a practical technique with which to evaluate, optimize, and compare imaging technologies and methods. Within simulation, the computerized phantom provides a virtual model of the patient’s anatomy and physiology. Imaging data can be generated from it as if it was a live patient using accurate models of the physics of the imaging and treatment process. With sophisticated simulation algorithms, it is possible to perform virtual experiments entirely on the computer. By serving as virtual patients, computational phantoms hold great promise in solving some of the most complex problems in modern medical physics. In this proposed symposium, we will present the history and recent developments of computational phantom models, share experiences in their application to advanced imaging and radiation applications, and discuss their promises and limitations. Learning Objectives: Understand the need and requirements of computational phantoms in medical physics research Discuss the developments and applications of computational phantoms Know the promises and limitations of computational phantoms in solving complex problems.« less

Toward Modeling the Intrinsic Complexity of Test Problems

ERIC Educational Resources Information Center

Shoufan, Abdulhadi

2017-01-01

The concept of intrinsic complexity explains why different problems of the same type, tackled by the same problem solver, can require different times to solve and yield solutions of different quality. This paper proposes a general four-step approach that can be used to establish a model for the intrinsic complexity of a problem class in terms of…

Investigating the Effect of Complexity Factors in Stoichiometry Problems Using Logistic Regression and Eye Tracking

ERIC Educational Resources Information Center

Tang, Hui; Kirk, John; Pienta, Norbert J.

2014-01-01

This paper includes two experiments, one investigating complexity factors in stoichiometry word problems, and the other identifying students' problem-solving protocols by using eye-tracking technology. The word problems used in this study had five different complexity factors, which were randomly assigned by a Web-based tool that we developed. The…

Process Mining-Based Method of Designing and Optimizing the Layouts of Emergency Departments in Hospitals.

PubMed

Rismanchian, Farhood; Lee, Young Hoon

2017-07-01

This article proposes an approach to help designers analyze complex care processes and identify the optimal layout of an emergency department (ED) considering several objectives simultaneously. These objectives include minimizing the distances traveled by patients, maximizing design preferences, and minimizing the relocation costs. Rising demand for healthcare services leads to increasing demand for new hospital buildings as well as renovating existing ones. Operations management techniques have been successfully applied in both manufacturing and service industries to design more efficient layouts. However, high complexity of healthcare processes makes it challenging to apply these techniques in healthcare environments. Process mining techniques were applied to address the problem of complexity and to enhance healthcare process analysis. Process-related information, such as information about the clinical pathways, was extracted from the information system of an ED. A goal programming approach was then employed to find a single layout that would simultaneously satisfy several objectives. The layout identified using the proposed method improved the distances traveled by noncritical and critical patients by 42.2% and 47.6%, respectively, and minimized the relocation costs. This study has shown that an efficient placement of the clinical units yields remarkable improvements in the distances traveled by patients.

Hybrid imaging in foot and ankle disorders.

PubMed

García Jiménez, R; García-Gómez, F J; Noriega Álvarez, E; Calvo Morón, C; Martín-Marcuartu, J J

Disorders of the foot and ankle are some of the most frequent ones affecting the musculoskeletal system and have a great impact on patients' quality of life. Accurate diagnosis is an important clinical challenge because of the complex anatomy and function of the foot, that make it difficult to locate the source of the pain by routine clinical examination. In the study of foot pathology, anatomical imaging (radiography, magnetic resonance imaging [MRI], ultrasound and computed tomography [CT]) and functional imaging (bone scan, positron emission tomography [PET] and MRI) techniques have been used. Hybrid imaging combines the advantages of morphological and functional studies in a synergistic way, helping the clinician manage complex problems. In this article we delve into the anatomy and biomechanics of the foot and ankle and describe the potential indications for the current hybrid techniques available for the study of foot and ankle disease. Copyright © 2017 Elsevier España, S.L.U. y SEMNIM. All rights reserved.

Nipple pain associated with breastfeeding: incorporating current neurophysiology into clinical reasoning.

PubMed

Amir, Lisa H; Jones, Lester E; Buck, Miranda L

2015-03-01

New mothers frequently experience breastfeeding problems, in particular nipple pain. This is often attributed to compression, skin damage, infection or dermatitis. To outline an integrated approach to breastfeeding pain assessment that seeks to enhance current practice. Our clinical reasoning model resolves the complexity of pain into three categories: local stimulation, external influences and central modulation. Tissue pathology, damage or inflammation leads to local stimulation of nociceptors. External influences such as creams and breast pumps, as well as factors related to the mother, the infant and the maternal-infant interaction, may exacerbate the pain. Central nervous system modulation includes the enhancement of nociceptive transmission at the spinal cord and modification of the descending inhibitory influences. A broad range of factors can modulate pain through central mechanisms including maternal illness, exhaustion, lack of support, anxiety, depression or history of abuse. General practitioners (GPs) can use this model to explain nipple pain in complex settings, thus increasing management options for women.

[Managment of acute low back pain without trauma - an algorithm].

PubMed

Melcher, Carolin; Wegener, Bernd; Jansson, Volkmar; Mutschler, Wolf; Kanz, Karl-Georg; Birkenmaier, Christof

2018-05-14

Low back pain is a common problem for primary care providers, outpatient clinics and A&E departments. The predominant symptoms are those of so-called "unspecific back pain", but serious pathologies can be concealed by the clinical signs. Especially less experienced colleagues have problems in treating these patients, as - despite the multitude of recommendations and guidelines - there is no generally accepted algorithm. After a literature search (Medline/Cochrane), 158 articles were selected from 15,000 papers and classified according to their level of evidence. These were attuned to the clinical guidelines of the orthopaedic and pain-physician associations in Europe, North America and overseas and the experience of specialists at LMU Munich, in order to achieve consistency with literature recommendations, as well as feasibility in everyday clinical work and optimised with practical relevance. An algorithm was formed to provide the crucial differential diagnosis of lumbar back pain according to its clinical relevance and to provide a plan of action offering reasonable diagnostic and therapeutic steps. As a consequence of distinct binary decisions, low back patients should be treated at any given time according to the guidelines, with emergencies detected, unnecessary diagnostic testing and interventions averted and reasonable treatment initiated pursuant to the underlying pathology. In the context of the available evidence, a clinical algorithm has been developed that translates the complex diagnostic testing of acute low back pain into a transparent, structured and systematic guideline. Georg Thieme Verlag KG Stuttgart · New York.

Multigrid Methods for Aerodynamic Problems in Complex Geometries

NASA Technical Reports Server (NTRS)

Caughey, David A.

1995-01-01

Work has been directed at the development of efficient multigrid methods for the solution of aerodynamic problems involving complex geometries, including the development of computational methods for the solution of both inviscid and viscous transonic flow problems. The emphasis is on problems of complex, three-dimensional geometry. The methods developed are based upon finite-volume approximations to both the Euler and the Reynolds-Averaged Navier-Stokes equations. The methods are developed for use on multi-block grids using diagonalized implicit multigrid methods to achieve computational efficiency. The work is focused upon aerodynamic problems involving complex geometries, including advanced engine inlets.

Cochrane Lecture 1997. What evidence do we need for evidence based medicine?

PubMed Central

Hart, J T

1997-01-01

As presently understood, evidence based medicine aims to advance practice from its traditional unverifiable mix of art and science to rational use of measurable inputs and outputs. In practice, however, its advocates accept uncritically a desocialised definition of science, assume that major clinical decisions are taken at the level of secondary specialist rather than primary generalist care, and ignore the multiple nature of most clinical problems, as well as the complexity of social problems within which clinical problems arise and have to be solved. These reductionist assumptions derive from the use of evidence based medicine as a tool for managed care in a transactional model for consultations. If these assumptions persist, they will strengthen reification of disease and promote the episodic output of process regardless of health outcome. We need to work within a different paradigm based on development of patients as co-producers rather than consumers, promoting continuing output of health gain through shared decisions using all relevant evidence, within a broader, socialised definition of science. Adoption of this model would require a major social and cultural shift for health professionals. This shift has already begun, promoted by changes in public attitudes to professional authority, changes in the relation of professionals to managers, and pressures for improved effectiveness and efficiency which, contrary to received wisdom, seem more likely to endorse cooperative than transactional clinical production. Progress on these lines is resisted by rapidly growing and extremely powerful economic and political interests. Health professionals and strategists have yet to recognise and admit the existence of this choice. PMID:9519124

Robust Decision Making: The Cognitive and Computational Modeling of Team Problem Solving for Decision Making under Complex and Dynamic Conditions

DTIC Science & Technology

2015-07-14

AFRL-OSR-VA-TR-2015-0202 Robust Decision Making: The Cognitive and Computational Modeling of Team Problem Solving for Decision Making under Complex...Computational Modeling of Team Problem Solving for Decision Making Under Complex and Dynamic Conditions 5a. CONTRACT NUMBER 5b. GRANT NUMBER FA9550-12-1...functioning as they solve complex problems, and propose the means to improve the performance of teams, under changing or adversarial conditions. By

Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations.

PubMed

Chan, Ya-Fen; Lu, Shou-En; Howe, Bill; Tieben, Hendrik; Hoeft, Theresa; Unützer, Jürgen

2016-02-01

Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. This was an observational study using patient registry. The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.

Future Directions for Clinical Research, Services, and Training: Evidence-Based Assessment Across Informants, Cultures, and Dimensional Hierarchies.

PubMed

Achenbach, Thomas M

2017-01-01

As the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) acknowledges, DSM diagnostic categories do not fit the real-world heterogeneity, comorbidity, and complexity of most mental health problems. Many efforts to develop and test evidence-based treatments also fail to take account of the heterogeneity, comorbidity, and complexity of problems seen in the community settings where most mental health services are rendered. Most community services cannot attain the treatment specificity and fidelity characterizing randomized controlled trials, which often yield larger therapeutic effects than when the tested treatments are tried in community services. Widely applicable evidence-based assessments (EBAs) can bridge gaps between evidence-based treatments and the diverse providers, cases, and conditions characterizing community services. To advance community services, intake EBAs can help providers take account of cross-informant discrepancies, parents' problems, multicultural variations, and hierarchical dimensional aspects of psychopathology. To capitalize on intake EBAs, progress and outcome EBAs should be used to identify changes and failures-to-change on which to base recalibrations of treatments. To strengthen therapeutic alliances, the results of intake, progress, and outcome EBAs can be shared with parents. To bridge gaps between research and services, it is recommended that training in clinical research and services should (a) focus on widely applicable EBAs as essential foundations for evidence-based practice; (b) systematically promote intake, progress, and outcome EBAs; and (c) equip psychologists to advance evidence-based practice in community services. To implement these recommendations, research is needed on how to increase use of EBAs, organize services around routine use of EBAs, and help providers base service decisions on EBAs.

Estimating Preferences for Complex Health Technologies: Lessons Learned and Implications for Personalized Medicine.

PubMed

Marshall, Deborah A; Gonzalez, Juan Marcos; MacDonald, Karen V; Johnson, F Reed

2017-01-01

We examine key study design challenges of using stated-preference methods to estimate the value of whole-genome sequencing (WGS) as a specific example of genomic testing. Assessing the value of WGS is complex because WGS provides multiple findings, some of which can be incidental in nature and unrelated to the specific health concerns that motivated the test. In addition, WGS results can include actionable findings (variants considered to be clinically useful and can be acted on), findings for which evidence for best clinical action is not available (variants considered clinically valid but do not meet as high of a standard for clinical usefulness), and findings of unknown significance. We consider three key challenges encountered in designing our national study on the value of WGS-layers of uncertainty, potential downstream consequences with endogenous aspects, and both positive and negative utility associated with testing information-and potential solutions as strategies to address these challenges. We conceptualized the decision to acquire WGS information as a series of sequential choices that are resolved separately. To determine the value of WGS information at the initial decision to undergo WGS, we used contingent valuation questions, and to elicit respondent preferences for reducing risks of health problems and the consequences of taking the steps to reduce these risks, we used a discrete-choice experiment. We conclude by considering the implications for evaluating the value of other complex health technologies that involve multiple forms of uncertainty. Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

Finite element models of the human shoulder complex: a review of their clinical implications and modelling techniques.

PubMed

Zheng, Manxu; Zou, Zhenmin; Bartolo, Paulo Jorge Da Silva; Peach, Chris; Ren, Lei

2017-02-01

The human shoulder is a complicated musculoskeletal structure and is a perfect compromise between mobility and stability. The objective of this paper is to provide a thorough review of previous finite element (FE) studies in biomechanics of the human shoulder complex. Those FE studies to investigate shoulder biomechanics have been reviewed according to the physiological and clinical problems addressed: glenohumeral joint stability, rotator cuff tears, joint capsular and labral defects and shoulder arthroplasty. The major findings, limitations, potential clinical applications and modelling techniques of those FE studies are critically discussed. The main challenges faced in order to accurately represent the realistic physiological functions of the shoulder mechanism in FE simulations involve (1) subject-specific representation of the anisotropic nonhomogeneous material properties of the shoulder tissues in both healthy and pathological conditions; (2) definition of boundary and loading conditions based on individualised physiological data; (3) more comprehensive modelling describing the whole shoulder complex including appropriate three-dimensional (3D) representation of all major shoulder hard tissues and soft tissues and their delicate interactions; (4) rigorous in vivo experimental validation of FE simulation results. Fully validated shoulder FE models would greatly enhance our understanding of the aetiology of shoulder disorders, and hence facilitate the development of more efficient clinical diagnoses, non-surgical and surgical treatments, as well as shoulder orthotics and prosthetics. © 2016 The Authors. International Journal for Numerical Methods in Biomedical Engineering published by John Wiley & Sons Ltd. © 2016 The Authors. International Journal for Numerical Methods in Biomedical Engineering published by John Wiley & Sons Ltd.

Fragile X--a challenge to models of the mind and to best clinical practice.

PubMed

Hay, David A

2008-06-01

Cornish et al. (2008, this issue) provide an excellent review of Fragile X a common but very complex cause of intellectual disability. They report on a cohort of such males of normal intelligence quotient (IQ) and socioeconomic status (SES), but who have deficits in selective attention and growing impairment in response inhibition. This paper has theoretical views for our models of the mind and clinical implications for families where Fragile X may never have been considered as a possible cause of some of the problems in male and female family members and possibly as well for other disorders such as attention deficit hyperactivity disorder (ADHD) and autism.

[Care continuity for patients with Prader-Willi syndrome during transition from childhood to adulthood].

PubMed

Saitoh, Shinji

2010-01-01

Prader-Willi syndrome(PWS) is a complex multisystem genetic disorder, of which characteristic phenotypes include neonatal hypotonia, hyperphagia resulting in obesity, mental retardation, hypogonadism, and behavioral and psychiatric problems. The diagnosis can be obtained as early as during neonatal period thanks to development of genetic testing. Clinical features of PWS will change depending on age, although core phenotypes of hyperphagia, obesity and psychiatric issues stay for lifetime. Therefore, integrated multidisciplinary approach starting from neonatal period is mandatory to ensure optimal management to improve lifelong quality of life. For successful transition from childhood to adulthood, multidisciplinary team need to share clinical information, and should keep the same policy about food, environment and psychiatric issues.

Versatile clinical information system design for emergency departments.

PubMed

Amouh, Teh; Gemo, Monica; Macq, Benoît; Vanderdonckt, Jean; El Gariani, Abdul Wahed; Reynaert, Marc S; Stamatakis, Lambert; Thys, Frédéric

2005-06-01

Compared to other hospital units, the emergency department presents some distinguishing characteristics of its own. Emergency health-care delivery is a collaborative process involving the contribution of several individuals who accomplish their tasks while working autonomously under pressure and sometimes with limited resources. Effective computerization of the emergency department information system presents a real challenge due to the complexity of the scenario. Current computerized support suffers from several problems, including inadequate data models, clumsy user interfaces, and poor integration with other clinical information systems. To tackle such complexity, we propose an approach combining three points of view, namely the transactions (in and out of the department), the (mono and multi) user interfaces and data management. Unlike current systems, we pay particular attention to the user-friendliness and versatility of our system. This means that intuitive user interfaces have been conceived and specific software modeling methodologies have been applied to provide our system with the flexibility and adaptability necessary for the individual and group coordinated tasks. Our approach has been implemented by prototyping a web-based, multiplatform, multiuser, and versatile clinical information system built upon multitier software architecture, using the Java programming language.

[Double diagnosis and forensic psychiatric opinion].

PubMed

Kocur, Józef; Trendak, Wiesława

2009-01-01

Addiction to alcohol or any other psychoactive substance can run parallel with other diseases or mental disorders. One can then observe co-occurrence and mutual interaction of dysfunctions typical of addiction and of other mental disorders that accompany addiction. That is why, clinical pictures of such states (double diagnosis) are usually less unique, have an unusual course and cause diagnostic and therapeutic difficulty. The problem of forensic psychiatric opinion and treatment of people with a double diagnosis is another aspect of these difficulties. It is caused by the fact that forensic psychiatric assessment of the mental state of such people requires taking into consideration a very complex clinical and legal situation triggered by the interference of various ethiopathogenetic and clinical disorders. It leads to the need for complex evaluation and reference to sanity or other signs of functioning within the current law should result, first of all, from the analyses directly pertaining to the influence of the diagnosed disorders on the state of patients with double diagnosis. The forensic psychiatric aspect of disorders connected with double diagnosis is particularly significant as there is a relatively high risk of behaviours posing a threat to public order in this group of patients.

Mapping of interaction domains between human repair proteins ERCC1 and XPF.

PubMed

de Laat, W L; Sijbers, A M; Odijk, H; Jaspers, N G; Hoeijmakers, J H

1998-09-15

ERCC1-XPF is a heterodimeric protein complexinvolved in nucleotide excision repair and recombinational processes. Like its homologous complex in Saccharomyces cerevisiae , Rad10-Rad1, it acts as a structure-specific DNA endonuclease, cleaving at duplex-single-stranded DNA junctions. In repair, ERCC1-XPF and Rad10-Rad1 make an incision on the the 5'-side of the lesion. No humans with a defect in the ERCC1 subunit of this protein complex have been identified and ERCC1-deficient mice suffer from severe developmental problems and signs of premature aging on top of a repair-deficient phenotype. Xeroderma pigmentosum group F patients carry mutations in the XPF subunit and generally show the clinical symptoms of mild DNA repair deficiency. All XP-F patients examined demonstrate reduced levels of XPF and ERCC1 protein, suggesting that proper complex formation is required for stability of the two proteins. To better understand the molecular and clinical consequences of mutations in the ERCC1-XPF complex, we decided to map the interaction domains between the two subunits. The XPF-binding domain comprises C-terminal residues 224-297 of ERCC1. Intriguingly, this domain resides outside the region of homology with its yeast Rad10 counterpart. The ERCC1-binding domain in XPF maps to C-terminal residues 814-905. ERCC1-XPF complex formation is established by a direct interaction between these two binding domains. A mutation from an XP-F patient that alters the ERCC1-binding domain in XPF indeed affects complex formation with ERCC1.

Mapping of interaction domains between human repair proteins ERCC1 and XPF.

PubMed Central

de Laat, W L; Sijbers, A M; Odijk, H; Jaspers, N G; Hoeijmakers, J H

1998-01-01

ERCC1-XPF is a heterodimeric protein complexinvolved in nucleotide excision repair and recombinational processes. Like its homologous complex in Saccharomyces cerevisiae , Rad10-Rad1, it acts as a structure-specific DNA endonuclease, cleaving at duplex-single-stranded DNA junctions. In repair, ERCC1-XPF and Rad10-Rad1 make an incision on the the 5'-side of the lesion. No humans with a defect in the ERCC1 subunit of this protein complex have been identified and ERCC1-deficient mice suffer from severe developmental problems and signs of premature aging on top of a repair-deficient phenotype. Xeroderma pigmentosum group F patients carry mutations in the XPF subunit and generally show the clinical symptoms of mild DNA repair deficiency. All XP-F patients examined demonstrate reduced levels of XPF and ERCC1 protein, suggesting that proper complex formation is required for stability of the two proteins. To better understand the molecular and clinical consequences of mutations in the ERCC1-XPF complex, we decided to map the interaction domains between the two subunits. The XPF-binding domain comprises C-terminal residues 224-297 of ERCC1. Intriguingly, this domain resides outside the region of homology with its yeast Rad10 counterpart. The ERCC1-binding domain in XPF maps to C-terminal residues 814-905. ERCC1-XPF complex formation is established by a direct interaction between these two binding domains. A mutation from an XP-F patient that alters the ERCC1-binding domain in XPF indeed affects complex formation with ERCC1. PMID:9722633

Students' conceptual performance on synthesis physics problems with varying mathematical complexity

NASA Astrophysics Data System (ADS)

Ibrahim, Bashirah; Ding, Lin; Heckler, Andrew F.; White, Daniel R.; Badeau, Ryan

2017-06-01

A body of research on physics problem solving has focused on single-concept problems. In this study we use "synthesis problems" that involve multiple concepts typically taught in different chapters. We use two types of synthesis problems, sequential and simultaneous synthesis tasks. Sequential problems require a consecutive application of fundamental principles, and simultaneous problems require a concurrent application of pertinent concepts. We explore students' conceptual performance when they solve quantitative synthesis problems with varying mathematical complexity. Conceptual performance refers to the identification, follow-up, and correct application of the pertinent concepts. Mathematical complexity is determined by the type and the number of equations to be manipulated concurrently due to the number of unknowns in each equation. Data were collected from written tasks and individual interviews administered to physics major students (N =179 ) enrolled in a second year mechanics course. The results indicate that mathematical complexity does not impact students' conceptual performance on the sequential tasks. In contrast, for the simultaneous problems, mathematical complexity negatively influences the students' conceptual performance. This difference may be explained by the students' familiarity with and confidence in particular concepts coupled with cognitive load associated with manipulating complex quantitative equations. Another explanation pertains to the type of synthesis problems, either sequential or simultaneous task. The students split the situation presented in the sequential synthesis tasks into segments but treated the situation in the simultaneous synthesis tasks as a single event.

Addressing the conundrum of multimorbidity in heart failure: Do we need a more strategic approach to improve health outcomes?

PubMed

Stewart, Simon; Riegel, Barbara; Thompson, David R

2016-02-01

There is clear evidence across the globe that the clinical complexity of patients presenting to hospital with the syndrome of heart failure is increasing - not only in terms of the presence of concurrent disease states, but with additional socio-demographic risk factors that complicate treatment. Management strategies that treat heart failure as the main determinant of health outcomes ignores the multiple and complex issues that will inevitably erode the efficacy and efficiency of current heart failure management programmes. This complex problem (or conundrum) requires a different way of thinking around the complex interactions that underpin poor outcomes in heart failure. In this context, we present the COordinated NUrse-led inteNsified Disease management for continuity of caRe for mUltiMorbidity in Heart Failure (CONUNDRUM-HF) matrix that may well inform future research and models of care to achieve better health outcomes in this rapidly increasing patient population. © The European Society of Cardiology 2015.

Acknowledging and allocating responsibility for clinical inertia in the management of Type 2 diabetes in primary care: a qualitative study.

PubMed

Zafar, A; Stone, M A; Davies, M J; Khunti, K

2015-03-01

Failure to intensify treatment in patients with Type 2 diabetes with suboptimal blood glucose control has been termed clinical inertia and has been shown to contribute to poorer patient outcomes. We aimed to identify and explore perceptions about clinical inertia from the perspective of primary healthcare providers. A qualitative study was conducted in Leicestershire and Northamptonshire, UK. Purposive sampling was based on healthcare providers working in primary care settings with 'higher' and 'lower' target achievement based on routine data. Twenty semi-structured interviews were conducted, face-to-face or by telephone. Thematic analysis was informed by the constant comparative approach. An important broad theme that emerged during the analysis was related to attribution and explanation of responsibility for clinical inertia. This included general willingness to accept a degree of responsibility for clinical inertia. In some cases, however, participants had inaccurate perceptions about levels of target achievement in their primary care centres, as indicated by routine data. Participants sought to lessen their own sense of accountability by highlighting patient-level barriers such as comorbidities and human fallibility, and also system-level barriers, particularly time constraints. Perceptions about ways of addressing the problem of clinical inertia were not seen as straightforward, further emphasizing a complex and cumulative pattern of barriers. In order to understand and address the problem of clinical inertia, provider, patient- and system-level barriers should be considered together rather than as separate issues. Acknowledgement of responsibility should be regarded positively as a motivator for change. © 2014 The Authors. Diabetic Medicine © 2014 Diabetes UK.

[Implications in primary health care of medical genetics and genomic in type 2 diabetes mellitus].

PubMed

Ramirez-Garcia, Sergio Alberto; Cabrera-Pivaral, Carlos E; Huacuja-Ruiz, Luis; Flores-Alvarado, Luis Javier; Pérez-García, Guillermo; González-Rico, José Luis; López-Velázquez, Alma; Topete-González, Luz Rosalba; Rosales-Góme, Roberto Carlos; Candelario-Mejía, Gerardo; Villa-Ruano, Nemesio

2013-01-01

Type 2 diabetes mellitus is a complex disease and a global health problem. Therefore, the first level of health care should handle the approaches of medical genetics and genomics to reduce its incidence. The aim is to present perspectives analyzed by our group in two areas of genetics and its clinical application. Emphasis is placed on the coexistence of several genetic forms clinically detectable in patients with diabetes, missing heritability associated with low penetrance, and epigenomics mechanism. It is discussed the effect of genetic variation associated with resistance to insulin, beta-cell dysfunction, shaft incretin, and other points of interest, such as thrifty genotype hypothesis, conformational disease, genetically unknown foods, phenocopies as clinically silent hypercortisolism, molecular phytopharmacology in the clinical management. Finally, the result was displayed in the Mexican population from genetic studies and new findings of clinical importance, such as involvement of melatonin and effect of variations in the number of copies in a genomic region.

A speech and psychological profile of treatment-seeking adolescents who stutter.

PubMed

Iverach, Lisa; Lowe, Robyn; Jones, Mark; O'Brian, Susan; Menzies, Ross G; Packman, Ann; Onslow, Mark

2017-03-01

The purpose of this study was to evaluate the relationship between stuttering severity, psychological functioning, and overall impact of stuttering, in a large sample of adolescents who stutter. Participants were 102 adolescents (11-17 years) seeking speech treatment for stuttering, including 86 boys and 16 girls, classified into younger (11-14 years, n=57) and older (15-17 years, n=45) adolescents. Linear regression models were used to evaluate the relationship between speech and psychological variables and overall impact of stuttering. The impact of stuttering during adolescence is influenced by a complex interplay of speech and psychological variables. Anxiety and depression scores fell within normal limits. However, higher self-reported stuttering severity predicted higher anxiety and internalizing problems. Boys reported externalizing problems-aggression, rule-breaking-in the clinical range, and girls reported total problems in the borderline-clinical range. Overall, higher scores on measures of anxiety, stuttering severity, and speech dissatisfaction predicted a more negative overall impact of stuttering. To our knowledge, this is the largest cohort study of adolescents who stutter. Higher stuttering severity, speech dissatisfaction, and anxiety predicted a more negative overall impact of stuttering, indicating the importance of carefully managing the speech and psychological needs of adolescents who stutter. Further research is needed to understand the relationship between stuttering and externalizing problems for adolescent boys who stutter. Copyright © 2016. Published by Elsevier Inc.

Optimal matching for prostate brachytherapy seed localization with dimension reduction.

PubMed

Lee, Junghoon; Labat, Christian; Jain, Ameet K; Song, Danny Y; Burdette, Everette C; Fichtinger, Gabor; Prince, Jerry L

2009-01-01

In prostate brachytherapy, x-ray fluoroscopy has been used for intra-operative dosimetry to provide qualitative assessment of implant quality. More recent developments have made possible 3D localization of the implanted radioactive seeds. This is usually modeled as an assignment problem and solved by resolving the correspondence of seeds. It is, however, NP-hard, and the problem is even harder in practice due to the significant number of hidden seeds. In this paper, we propose an algorithm that can find an optimal solution from multiple projection images with hidden seeds. It solves an equivalent problem with reduced dimensional complexity, thus allowing us to find an optimal solution in polynomial time. Simulation results show the robustness of the algorithm. It was validated on 5 phantom and 18 patient datasets, successfully localizing the seeds with detection rate of > or = 97.6% and reconstruction error of < or = 1.2 mm. This is considered to be clinically excellent performance.

Cognitive Behavioural Suicide Prevention for Male Prisoners: Case examples

PubMed Central

Pratt, Daniel; Gooding, Patricia; Awenat, Yvonne; Eccles, Steve; Tarrier, Nicholas

2015-01-01

Suicide is a serious public health problem but a problem that is preventable. This complex and challenging problem is particularly prevalent amongst prisoners; associated with a five-fold increase in risk compared to the general community. Being in prison can lead people to experience fear, distrust, lack of control, isolation, and shame, which is often experienced as overwhelming and intolerable with some choosing suicide as a way to escape. Few effective psychological interventions exist to prevent suicide although cognitive behaviour therapies appear to offer some promise. Offering cognitive behaviour suicide prevention (CBSP) therapy to high risk prisoners may help to reduce the likelihood of preventable self-inflicted deaths. In this paper we present three cases drawn from a randomised controlled trial designed to investigate the feasibility of CBSP for male prisoners. Implications of the current findings for future research and clinical practice are considered. PMID:27713616

Antitumor Activity of Monoterpenes Found in Essential Oils

PubMed Central

Sobral, Marianna Vieira; Xavier, Aline Lira; Lima, Tamires Cardoso; de Sousa, Damião Pergentino

2014-01-01

Cancer is a complex genetic disease that is a major public health problem worldwide, accounting for about 7 million deaths each year. Many anticancer drugs currently used clinically have been isolated from plant species or are based on such substances. Accumulating data has revealed anticancer activity in plant-derived monoterpenes. In this review the antitumor activity of 37 monoterpenes found in essential oils is discussed. Chemical structures, experimental models, and mechanisms of action for bioactive substances are presented. PMID:25401162

Differential diagnosis of hyperkalemia: an update to a complex problem

PubMed Central

Eleftheriadis, T; Leivaditis, K; Antoniadi, G; Liakopoulos, V

2012-01-01

Hyperkalemia is a relative common and sometimes life threatening electorlyte disorder. Although its symptomatic treatment is relatively easy, since precise therapeutic algorithms are available, its differential diagnosis is more complicated. The present review aims to unfold the differential diagnosis of hypekalemia using a pathophysiological, albeit clinically useful, approach. The basic elements of potassium homeostasis are provided, the causes of hyperkalemia are categorized and analysed and finally the required for the diferrential diagnosis laboratory tests are mentioned. PMID:23935306

Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part I: biology, biomechanics, anatomy and an exercise-based approach.

PubMed

Abat, F; Alfredson, H; Cucchiarini, M; Madry, H; Marmotti, A; Mouton, C; Oliveira, J M; Pereira, H; Peretti, G M; Romero-Rodriguez, D; Spang, C; Stephen, J; van Bergen, C J A; de Girolamo, L

2017-12-01

Chronic tendinopathies represent a major problem in the clinical practice of sports orthopaedic surgeons, sports doctors and other health professionals involved in the treatment of athletes and patients that perform repetitive actions. The lack of consensus relative to the diagnostic tools and treatment modalities represents a management dilemma for these professionals. With this review, the purpose of the ESSKA Basic Science Committee is to establish guidelines for understanding, diagnosing and treating this complex pathology.

Formative feedback and scaffolding for developing complex problem solving and modelling outcomes

NASA Astrophysics Data System (ADS)

Frank, Brian; Simper, Natalie; Kaupp, James

2018-07-01

This paper discusses the use and impact of formative feedback and scaffolding to develop outcomes for complex problem solving in a required first-year course in engineering design and practice at a medium-sized research-intensive Canadian university. In 2010, the course began to use team-based, complex, open-ended contextualised problems to develop problem solving, communications, teamwork, modelling, and professional skills. Since then, formative feedback has been incorporated into: task and process-level feedback on scaffolded tasks in-class, formative assignments, and post-assignment review. Development in complex problem solving and modelling has been assessed through analysis of responses from student surveys, direct criterion-referenced assessment of course outcomes from 2013 to 2015, and an external longitudinal study. The findings suggest that students are improving in outcomes related to complex problem solving over the duration of the course. Most notably, the addition of new feedback and scaffolding coincided with improved student performance.

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert

PubMed Central

Schmidt, Henk G.; Rikers, Remy M. J. P.; Custers, Eugene J. F. M.; Splinter, Ted A. W.; van Saase, Jan L. C. M.

2010-01-01

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices’ decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases. PMID:20354726

Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert.

PubMed

Mamede, Sílvia; Schmidt, Henk G; Rikers, Remy M J P; Custers, Eugene J F M; Splinter, Ted A W; van Saase, Jan L C M

2010-11-01

Contrary to what common sense makes us believe, deliberation without attention has recently been suggested to produce better decisions in complex situations than deliberation with attention. Based on differences between cognitive processes of experts and novices, we hypothesized that experts make in fact better decisions after consciously thinking about complex problems whereas novices may benefit from deliberation-without-attention. These hypotheses were confirmed in a study among doctors and medical students. They diagnosed complex and routine problems under three conditions, an immediate-decision condition and two delayed conditions: conscious thought and deliberation-without-attention. Doctors did better with conscious deliberation when problems were complex, whereas reasoning mode did not matter in simple problems. In contrast, deliberation-without-attention improved novices' decisions, but only in simple problems. Experts benefit from consciously thinking about complex problems; for novices thinking does not help in those cases.

Clarithromycin therapy for bacteremic Mycobacterium avium complex disease. A randomized, double-blind, dose-ranging study in patients with AIDS. AIDS Clinical Trials Group Protocol 157 Study Team.

PubMed

Chaisson, R E; Benson, C A; Dube, M P; Heifets, L B; Korvick, J A; Elkin, S; Smith, T; Craft, J C; Sattler, F R

1994-12-15

To determine the antimicrobial activity and tolerability of clarithromycin for treating bacteremic Mycobacterium avium complex disease in patients with the acquired immunodeficiency syndrome (AIDS). A randomized, double-blind, dose-ranging study. Outpatient clinics. 154 patients with human immunodeficiency virus (HIV) infection and blood cultures positive for M. avium complex who had symptomatic disease. Random assignment to clarithromycin at dosages of 500 mg, 1000 mg, or 2000 mg twice daily for 12 weeks. Median number of colony-forming units of M. avium complex per milliliter of blood. Clarithromycin decreased mycobacterial CFUs from 2.7 to 2.8 log 10/mL of blood at baseline to less than 0 log 10/mL during follow-up (P < 0.0001). After 2 weeks, patients receiving 500 mg twice daily were less likely to be culture negative than were patients receiving 1000 or 2000 mg twice daily (11% compared with 33% or 29%; P = 0.08). At 6 weeks, the median number of CFUs of M. avium complex/mL of blood was 0 or 1 for all three groups. Clarithromycin-resistant isolates of M. avium complex developed in 46% of patients at a median of 16 weeks. Median survival was longer in patients assigned to 500 mg twice daily (median, 249 days) than in patients assigned to 1000 mg or 2000 mg. Death in the first 12 weeks was lowest in the 500-mg group (P = 0.007). Clarithromycin therapy acutely decreased M. avium complex bacteremia in patients with HIV infection by more than 99%. Clarithromycin, 500 mg twice daily, was well tolerated and associated with better survival. Emergence of clarithromycin-resistant organisms was an important problem.

[Research on non-rigid registration of multi-modal medical image based on Demons algorithm].

PubMed

Hao, Peibo; Chen, Zhen; Jiang, Shaofeng; Wang, Yang

2014-02-01

Non-rigid medical image registration is a popular subject in the research areas of the medical image and has an important clinical value. In this paper we put forward an improved algorithm of Demons, together with the conservation of gray model and local structure tensor conservation model, to construct a new energy function processing multi-modal registration problem. We then applied the L-BFGS algorithm to optimize the energy function and solve complex three-dimensional data optimization problem. And finally we used the multi-scale hierarchical refinement ideas to solve large deformation registration. The experimental results showed that the proposed algorithm for large de formation and multi-modal three-dimensional medical image registration had good effects.

The Behavioral Pediatrics Feeding Assessment Scale is a reliable and valid tool for Greek children.

PubMed

Sdravou, Katerina S L T; Evangeliou, Athanasios; Tentzidou, Kyriaki; Sotiriadou, Fotini; Stasinou, Eleanna; Fotoulaki, Maria

2018-05-11

Development of normal feeding is a highly complex sensorimotor process that depends upon the integration of neurological maturation, internal motivation and experiential learning (1-3). Disruption of the child's feeding process can lead to feeding problems during infancy and early childhood. One of the most widely used and validated scales for measuring whether a child's feeding problem has clinical significance is the Behavioral Pediatric Feeding Assessment Scale (BPFAS) (4). The objective of this study was to translate the BPFAS into Greek and culturally adapt the scale to evaluate the psychometric properties among the Greek parents of normally developing children. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Explicitly solvable complex Chebyshev approximation problems related to sine polynomials

NASA Technical Reports Server (NTRS)

Freund, Roland

1989-01-01

Explicitly solvable real Chebyshev approximation problems on the unit interval are typically characterized by simple error curves. A similar principle is presented for complex approximation problems with error curves induced by sine polynomials. As an application, some new explicit formulae for complex best approximations are derived.

Addressing Complex Challenges through Adaptive Leadership: A Promising Approach to Collaborative Problem Solving

ERIC Educational Resources Information Center

Nelson, Tenneisha; Squires, Vicki

2017-01-01

Organizations are faced with solving increasingly complex problems. Addressing these issues requires effective leadership that can facilitate a collaborative problem solving approach where multiple perspectives are leveraged. In this conceptual paper, we critique the effectiveness of earlier leadership models in tackling complex organizational…

Informing family members of individuals with Lynch syndrome: a guideline for clinical geneticists.

PubMed

Menko, Fred H; Aalfs, Cora M; Henneman, Lidewij; Stol, Yrrah; Wijdenes, Miranda; Otten, Ellen; Ploegmakers, Marleen M J; Legemaate, Johan; Smets, Ellen M A; de Wert, Guido M W R; Tibben, Aad

2013-06-01

The diagnosis of Lynch syndrome can lead to the prevention of colorectal cancer through periodic colonoscopies and removal of premalignant lesions in susceptible individuals. Therefore, predisposed individuals identified by mutation analysis are advised to inform their at-risk relatives about the options of predictive DNA testing and preventive measures. However, it has now been established that more than half of these relatives do not receive the necessary information. Barriers in conveying information include family communication problems and variable attitudes and practice among clinical geneticists. In this complex field, both medical, psychological, ethical and juridical aspects deserve consideration. Here we summarize the development of a revised guideline for clinical geneticists that allows a more active role of the geneticist, aimed at improving procedures to inform family members in Lynch syndrome and other hereditary and familial cancer syndromes.

An integrated approach to telemonitoring noncommunicable diseases: best practice from the European innovation partnership on active and healthy ageing.

PubMed

Bourret, Rodolphe; Bousquet, Jean

2013-01-01

The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) has prioritized noncommunicable diseases (NCDs). An innovative integrated health system built around medical systems and strategic partnerships is proposed to combat NCDs. Information and communication technology (ICT) is needed for the implementation of integrated care in a medical systems approach. The Teaching Hospital of Montpellier has set up the clinic and uses IP-Soins as an ICT tool. Patients with NCDs will be referred to the chronic disease clinic of the hospital by a primary care physician. This paper reviews the complexity of NCDs intertwined with ageing. It gives an overview of the problem. It presents an innovative approach in the implementation of a clinical information system in a "SaaS" (Software as a Service) mode.

Practical ethical theory for nurses responding to complexity in care.

PubMed

Fairchild, Roseanne Moody

2010-05-01

In the context of health care system complexity, nurses need responsive leadership and organizational support to maintain intrinsic motivation, moral sensitivity and a caring stance in the delivery of patient care. The current complexity of nurses' work environment promotes decreases in work motivation and moral satisfaction, thus creating motivational and ethical dissonance in practice. These and other work-related factors increase emotional stress and burnout for nurses, prompting both new and seasoned nurse professionals to leave their current position, or even the profession. This article presents a theoretical conceptual model for professional nurses to review and make sense of the ethical reasoning skills needed to maintain a caring stance in relation to the competing values that must coexist among nurses, health care administrators, patients and families in the context of the complex health care work environments in which nurses are expected to practice. A model, Nurses' Ethical Reasoning Skills, is presented as a framework for nurses' thinking through and problem solving ethical issues in clinical practice in the context of complexity in health care.

Bovine pasteurellosis and other bacterial infections of the respiratory tract.

PubMed

Griffin, Dee

2010-03-01

Despite technological, biologic, and pharmacologic advances the bacterial component of the bovine respiratory disease (BRD) complex continues to have a major adverse effect on the health and wellbeing of stocker and feeder cattle. Overlooked in this disappointing assessment is evaluation of the effects that working with younger, lighter-weight cattle have on managing the bacterial component of the BRD complex. Most problems associated with BRD come from cattle taken from and comingled with cattle operations that have inconsistent or nonexistent cattle health management. This article reviews the biologic, clinical, and management aspects of Pasteurella multocida, Mannheimia haemolytica, Histophilus somni, and Mycoplasma bovis, primarily as related to current production management considerations of stocker and feeder cattle. Copyright 2010 Elsevier Inc. All rights reserved.

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

PubMed Central

Siriwardena, A Niroshan; Apekey, Tanefa; Tilling, Michelle; Harrison, Andrew; Dyas, Jane V; Middleton, Hugh C; Ørner, Roderick; Sach, Tracey; Dewey, Michael; Qureshi, Zubair M

2009-01-01

Background Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation. Trial Registration ClinicalTrials.gov ID ISRCTN55001433 – PMID:19171070

Language functions in preterm-born children: a systematic review and meta-analysis.

PubMed

van Noort-van der Spek, Inge L; Franken, Marie-Christine J P; Weisglas-Kuperus, Nynke

2012-04-01

Preterm-born children (<37 weeks' gestation) have higher rates of language function problems compared with term-born children. It is unknown whether these problems decrease, deteriorate, or remain stable over time. The goal of this research was to determine the developmental course of language functions in preterm-born children from 3 to 12 years of age. Computerized databases Embase, PubMed, Web of Knowledge, and PsycInfo were searched for studies published between January 1995 and March 2011 reporting language functions in preterm-born children. Outcome measures were simple language function assessed by using the Peabody Picture Vocabulary Test and complex language function assessed by using the Clinical Evaluation of Language Fundamentals. Pooled effect sizes (in terms of Cohen's d) and 95% confidence intervals (CI) for simple and complex language functions were calculated by using random-effects models. Meta-regression was conducted with mean difference of effect size as the outcome variable and assessment age as the explanatory variable. Preterm-born children scored significantly lower compared with term-born children on simple (d = -0.45 [95% CI: -0.59 to -0.30]; P < .001) and on complex (d = -0.62 [95% CI: -0.82 to -0.43]; P < .001) language function tests, even in the absence of major disabilities and independent of social economic status. For complex language function (but not for simple language function), group differences between preterm- and term-born children increased significantly from 3 to 12 years of age (slope = -0.05; P = .03). While growing up, preterm-born children have increasing difficulties with complex language function.

Plastic Surgery Challenges in War Wounded II: Regenerative Medicine

PubMed Central

Valerio, Ian L.; Sabino, Jennifer M.; Dearth, Christopher L.

2016-01-01

Background: A large volume of service members have sustained complex injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF). These injuries are complicated by contamination with particulate and foreign materials, have high rates of bacterial and/or fungal infections, are often composite-type defects with massive soft tissue wounds, and usually have multisystem involvement. While traditional treatment modalities remain a mainstay for optimal wound care, traditional reconstruction approaches alone may be inadequate to fully address the scope and magnitude of such massive complex wounds. As a result of these difficult clinical problems, the use of regenerative medicine therapies, such as autologous adipose tissue grafting, stem cell therapies, nerve allografts, and dermal regenerate templates/extracellular matrix scaffolds, is increased as adjuncts to traditional reconstructive measures. Basic and Clinical Science Advances: The beneficial applications of regenerative medicine therapies have been well characterized in both in vitro studies and in vivo animal studies. The use of these regenerative medicine techniques in the treatment of combat casualty injuries has been increasing throughout the recent war conflicts. Clinical Care Relevance: Military medicine has shown positive results when utilizing certain regenerative medicine modalities in treating complex war wounds. As a result, multi-institution clinical trials are underway to further evaluate these observations and reconstruction measures. Conclusion: Successful combat casualty wound care often requires a combination of traditional aspects of the reconstructive ladder/elevator with adoption of various regenerative medicine therapies. Due to the recent OIF/OEF conflicts, a high volume of combat casualties have benefited from adoption of regenerative medicine therapies and increased access to innovative clinical trials. Furthermore, many of these patients have had long-term follow-up to report on clinical outcomes that substantiate current treatment paradigms and concepts within regenerative medicine, reconstructive, and rehabilitation care. These results are applicable to not only combat casualty care but also to nonmilitary patients. PMID:27679752

From Sour Grapes to Low-Hanging Fruit: A Case Study Demonstrating a Practical Strategy for Natural Language Processing Portability.

PubMed

Johnson, Stephen B; Adekkanattu, Prakash; Campion, Thomas R; Flory, James; Pathak, Jyotishman; Patterson, Olga V; DuVall, Scott L; Major, Vincent; Aphinyanaphongs, Yindalon

2018-01-01

Natural Language Processing (NLP) holds potential for patient care and clinical research, but a gap exists between promise and reality. While some studies have demonstrated portability of NLP systems across multiple sites, challenges remain. Strategies to mitigate these challenges can strive for complex NLP problems using advanced methods (hard-to-reach fruit), or focus on simple NLP problems using practical methods (low-hanging fruit). This paper investigates a practical strategy for NLP portability using extraction of left ventricular ejection fraction (LVEF) as a use case. We used a tool developed at the Department of Veterans Affair (VA) to extract the LVEF values from free-text echocardiograms in the MIMIC-III database. The approach showed an accuracy of 98.4%, sensitivity of 99.4%, a positive predictive value of 98.7%, and F-score of 99.0%. This experience, in which a simple NLP solution proved highly portable with excellent performance, illustrates the point that simple NLP applications may be easier to disseminate and adapt, and in the short term may prove more useful, than complex applications.

Systems biomarkers as acute diagnostics and chronic monitoring tools for traumatic brain injury

NASA Astrophysics Data System (ADS)

Wang, Kevin K. W.; Moghieb, Ahmed; Yang, Zhihui; Zhang, Zhiqun

2013-05-01

Traumatic brain injury (TBI) is a significant biomedical problem among military personnel and civilians. There exists an urgent need to develop and refine biological measures of acute brain injury and chronic recovery after brain injury. Such measures "biomarkers" can assist clinicians in helping to define and refine the recovery process and developing treatment paradigms for the acutely injured to reduce secondary injury processes. Recent biomarker studies in the acute phase of TBI have highlighted the importance and feasibilities of identifying clinically useful biomarkers. However, much less is known about the subacute and chronic phases of TBI. We propose here that for a complex biological problem such as TBI, multiple biomarker types might be needed to harness the wide range of pathological and systemic perturbations following injuries, including acute neuronal death, neuroinflammation, neurodegeneration and neuroregeneration to systemic responses. In terms of biomarker types, they range from brain-specific proteins, microRNA, genetic polymorphism, inflammatory cytokines and autoimmune markers and neuro-endocrine hormones. Furthermore, systems biology-driven biomarkers integration can help present a holistic approach to understanding scenarios and complexity pathways involved in brain injury.

Exploring recruitment issues in stroke research: a qualitative study of nurse researchers' experiences.

PubMed

Boxall, Leigh; Hemsley, Anthony; White, Nicola

2016-05-01

To explore the practice of experienced stroke nurse researchers to understand the issues they face in recruiting participants. Participant recruitment is one of the greatest challenges in conducting clinical research, with many trials failing due to recruitment problems. Stroke research is a particularly difficult area in which to recruit; however various strategies can improve participation. Analysis revealed three main types of problems for recruiting participants to stroke research: those related to patients, those related to the nurse researcher, and those related to the study itself. Impairments affecting capacity to consent, the acute recruitment time frame of most stroke trials, paternalism by nurse researchers, and low public awareness were especially pertinent. The disabling nature of a stroke, which often includes functional and cognitive impairments, and the acute stage of illness at which patients are appropriate for many trials, make recruiting patients particularly complex and challenging. An awareness of the issues surrounding the recruitment of stroke patients may help researchers in designing and conducting trials. Future work is needed to address the complexities of obtaining informed consent when patient capacity is compromised.

The Bright Side of Being Blue: Depression as an Adaptation for Analyzing Complex Problems

ERIC Educational Resources Information Center

Andrews, Paul W.; Thomson, J. Anderson, Jr.

2009-01-01

Depression is the primary emotional condition for which help is sought. Depressed people often report persistent rumination, which involves analysis, and complex social problems in their lives. Analysis is often a useful approach for solving complex problems, but it requires slow, sustained processing, so disruption would interfere with problem…

A process for Decision-making after Pilot and feasibility Trials (ADePT): development following a feasibility study of a complex intervention for pelvic organ prolapse

PubMed Central

2013-01-01

Background Current Medical Research Council (MRC) guidance on complex interventions advocates pilot trials and feasibility studies as part of a phased approach to the development, testing, and evaluation of healthcare interventions. In this paper we discuss the results of a recent feasibility study and pilot trial for a randomized controlled trial (RCT) of pelvic floor muscle training for prolapse (ClinicalTrials.gov: NCT01136889). The ways in which researchers decide to respond to the results of feasibility work may have significant repercussions for both the nature and degree of tension between internal and external validity in a definitive trial. Methods We used methodological issues to classify and analyze the problems that arose in the feasibility study. Four centers participated with the aim of randomizing 50 women. Women were eligible if they had prolapse of any type, of stage I to IV, and had a pessary successfully fitted. Postal questionnaires were administered at baseline, 6 months, and 7 months post-randomization. After identifying problems arising within the pilot study we then sought to locate potential solutions that might minimize the trade-off between a subsequent explanatory versus pragmatic trial. Results The feasibility study pointed to significant potential problems in relation to participant recruitment, features of the intervention, acceptability of the intervention to participants, and outcome measurement. Finding minimal evidence to support our decision-making regarding the transition from feasibility work to a trial, we developed a systematic process (A process for Decision-making after Pilot and feasibility Trials (ADePT)) which we subsequently used as a guide. The process sought to: 1) encourage the systematic identification and appraisal of problems and potential solutions; 2) improve the transparency of decision-making processes; and 3) reveal the tensions that exist between pragmatic and explanatory choices. Conclusions We have developed a process that may aid researchers in their attempt to identify the most appropriate solutions to problems identified within future pilot and feasibility RCTs. The process includes three key steps: a decision about the type of problem, the identification of all solutions (whether addressed within the intervention, trial design or clinical context), and a systematic appraisal of these solutions. PMID:24160371

The clinical engineer: a ghost hunter or manager of EMI.

PubMed

Paperman, W D; David, Y

1998-01-01

The management of EMI and risk control in the clinical environment presents the clinical engineer with new challenges and responsibilities. The keys to successfully meeting these challenges and responsibilities are education, cooperation, and the ability to be creative in the quest for solutions to problems of ever-increasing complexity. Experience in detecting and analyzing test results, which is gained over time, enhances the skills that clinical engineering professionals bring to this challenge. Attention to EMI risks has been influenced by a number of factors, including a spirit of cooperation between manufacturers and users, concerns over patient care and perceived product efficacy, and an increasing number of regulations by European and U.S. regulatory agencies. As a result, device emissions are being reduced and device immunity to EMI is improving. Further improvements in device immunity are still needed. The radio spectrum with regard to intentional radiators is in a continual state of flux. As industry attempts to improve labor efficiency through the use of radio communications, new and higher-powered sources of RF--both internal and external to the physical plant--appear each day in the clinical environment. Since the distance between intentional radiators and potentially susceptible devices is usually beyond the control of an institution, industry must continue to reduce device susceptibility. There should be a stronger dialogue between institutions (even if they do not have proactive EMI reduction programs) and manufacturers to identify ways to improve device immunity to EMI and to increase product designers' and users' awareness of potential problems.

Performance of subjects with and without severe mental illness on a clinical test of problem solving.

PubMed

Marshall, R C; McGurk, S R; Karow, C M; Kairy, T J; Flashman, L A

2006-06-01

Severe mental illness is associated with impairments in executive functions, such as conceptual reasoning, planning, and strategic thinking all of which impact problem solving. The present study examined the utility of a novel assessment tool for problem solving, the Rapid Assessment of Problem Solving Test (RAPS) in persons with severe mental illness. Subjects were 47 outpatients with severe mental illness and an equal number healthy controls matched for age and gender. Results confirmed all hypotheses with respect to how subjects with severe mental illness would perform on the RAPS. Specifically, the severely mentally ill subjects (1) solved fewer problems on the RAPS, (2) when they did solve problems on the test, they did so far less efficiently than their healthy counterparts, and (3) the two groups differed markedly in the types of questions asked on the RAPS. The healthy control subjects tended to take a systematic, organized, but not always optimal approach to solving problems on the RAPS. The subjects with severe mental illness used some of the problem solving strategies of the healthy controls, but their performance was less consistent and tended to deteriorate when the complexity of the problem solving task increased. This was reflected by a high degree of guessing in lieu of asking constraint questions, particularly if a category-limited question was insufficient to continue the problem solving effort.

Understanding Wicked Problems: A Key to Advancing Environmental Health Promotion

ERIC Educational Resources Information Center

Kreuter, Marshall W.; De Rosa, Christopher; Howze, Elizabeth H.; Baldwin, Grant T.

2004-01-01

Complex environmental health problems--like air and water pollution, hazardous waste sites, and lead poisoning--are in reality a constellation of linked problems embedded in the fabric of the communities in which they occur. These kinds of complex problems have been characterized by some as "wicked problems" wherein stakeholders may have…

Acute myeloid leukemia in the real world: why population-based registries are needed

PubMed Central

Lazarevic, Vladimir; Hörstedt, Ann-Sofi; Hagberg, Oskar; Höglund, Martin

2012-01-01

Population-based registries may provide data complementary to that from basic science and clinical intervention studies, all of which are essential for establishing recommendations for the management of patients in the real world. The same quality criteria apply for the evidence-based label, and both high representation and good data quality are crucial in registry studies. Registries with high coverage of the target population reduce the impact of selection on outcome and the subsequent problem with extrapolating data to nonstudied populations. Thus, data useful for clinical decision in situations not well covered by clinical studies can be provided. The potential clinical impact of data from population-based studies is exemplified with analyses from the Swedish Acute Leukemia Registry containing more than 3300 acute myeloid leukemia (AML) patients diagnosed between 1997 and 2006 with a median follow-up of 6.2 years on (1) the role of intensive combination chemotherapy for older patients with AML, (2) the impact of allogeneic stem cell transplantation on survival of younger patients with AML, and (3) the continuing problem with early deaths in acute promyelocytic leukemia. We also present the first Web-based dynamic graph showing the complex interaction between age, performance status, the proportion of patients given intensive treatment, early death rate, complete remission rate, use of allogeneic transplants, and overall survival in AML (non-AML). PMID:22383796

Pedagogical Approaches to Diagnostic Imaging Education: A Narrative Review of the Literature

PubMed Central

Linaker, Kathleen L.

2015-01-01

Objective The purpose of this study was to examine literature on how radiology is taught and learned by both radiology residents and undergraduates in the health professions. Methods A review of the literature was performed using relevant key words. Articles were retrieved through December 2012 using PubMed, ScienceDirect, ERIC, Proquest, and ICL databases along with a manual review of references. Results Of the 4716 unique abstracts reviewed by the author, 91 were found to be relevant to the purpose of this study. The literature retrieved reported pedagogical approaches to teaching radiology including the following: problem solving, technology as teacher, independent learning tools, visiting lectureships, case based teaching, and conferences. There was some exploration of the relative effectiveness of educational formats. Suggestions for future research identify 7 areas of relative consistency. Conclusion Radiology is a clinical skill that requires integration science, clinical information, clinical experiences, and information recorded on diagnostic imaging studies. The research in this area focuses on problem solving, the use of algorithm/scripts, introducing uncertainty in clinical scenarios, incorporating technology in learning environments, active learning techniques, and methods of independent learning. Although the literature in this area is still in its infancy, the research examining the relative effectiveness of these various educational formats is often contradictory, suggesting that this is a complex area of study with numerous factors influencing student learning. PMID:26770173

Acute myeloid leukemia in the real world: why population-based registries are needed.

PubMed

Juliusson, Gunnar; Lazarevic, Vladimir; Hörstedt, Ann-Sofi; Hagberg, Oskar; Höglund, Martin

2012-04-26

Population-based registries may provide data complementary to that from basic science and clinical intervention studies, all of which are essential for establishing recommendations for the management of patients in the real world. The same quality criteria apply for the evidence-based label, and both high representation and good data quality are crucial in registry studies. Registries with high coverage of the target population reduce the impact of selection on outcome and the subsequent problem with extrapolating data to nonstudied populations. Thus, data useful for clinical decision in situations not well covered by clinical studies can be provided. The potential clinical impact of data from population-based studies is exemplified with analyses from the Swedish Acute Leukemia Registry containing more than 3300 acute myeloid leukemia (AML) patients diagnosed between 1997 and 2006 with a median follow-up of 6.2 years on (1) the role of intensive combination chemotherapy for older patients with AML, (2) the impact of allogeneic stem cell transplantation on survival of younger patients with AML, and (3) the continuing problem with early deaths in acute promyelocytic leukemia. We also present the first Web-based dynamic graph showing the complex interaction between age, performance status, the proportion of patients given intensive treatment, early death rate, complete remission rate, use of allogeneic transplants, and overall survival in AML (non-AML).

Chasing the Mirage: a grounded theory of the clinical reasoning processes that Registered Nurses use to recognize delirium.

PubMed

El Hussein, Mohamed; Hirst, Sandra

2016-02-01

The aim of this study was to construct a grounded theory that explains the clinical reasoning processes that registered nurses use to recognize delirium in older adults in acute care hospitals. Delirium is under-recognized in acute hospital settings, this may stem from underdeveloped clinical reasoning processes. Little is known about registered nurses' (RNs) clinical reasoning processes in complex situations such as delirium recognition. A grounded theory approach was used to analyse interview data about the clinical reasoning processes of RNs in acute hospital settings. Seventeen RNs were recruited. Concurrent data collection and comparative analysis and theoretical sampling were conducted in 2013-2014. The core category to emerge from the data was 'chasing the mirage', which describes RNs' clinical reasoning processes to recognize delirium during their interaction with older adults. Understanding the reasoning that contributes to delirium under-recognition provides a strategy by which, this problem can be brought to the forefront of RNs' awareness and intervention. Delirium recognition will contribute to quality care for older adults. © 2015 John Wiley & Sons Ltd.

Clinical aspects of the Mayo/IBM PACS project

NASA Astrophysics Data System (ADS)

Forbes, Glenn S.; Morin, Richard L.; Pavlicek, William

1991-07-01

A joint project between Mayo Clinic and IBM to develop a picture archival and communications system has been under development for three years. This project began as a potential solution to a pressing archival problem in magnetic resonance imaging. The project has grown to encompass a much larger sphere of activity including workstations, image retrieval, and report archival. This report focuses on the clinical aspects involved in the design, development, and implementation of such a system. In particular, emphasis is placed on the clinical impact of the system both inside and outside of the radiology department. The primary concerns have centered on fidelity of archival data, ease of use, and diagnostic efficacy. The project to date has been limited to neuroradiology practice. This group consists of nine staff radiologists and fellows. Administrative policy decisions regarding the accessibility and available of digital data in the clinical environment have been much more difficult and complex than originally conceived. Based on the observations thus far, the authors believe the system will become a useful and valuable adjunct to clinical practice of radiology.

[Revision hip arthroplasty by Waldemar Link custom-made total hip prosthesis].

PubMed

Medenica, Ivica; Luković, Milan; Radoicić, Dragan

2010-02-01

The number of patients undergoing hip arthroplasty revision is constantly growing. Especially, complex problem is extensive loss of bone stock and pelvic discontinuity that requires reconstruction. The paper presented a 50-year old patient, who ten years ago underwent a total cement artrhroplasty of the left hip. A year after the primary operation the patient had difficulties in walking without crutches. Problems intensified in the last five years, the patient had severe pain, totally limited movement in the left hip and could not walk at all. Radiographically, we found loose femoral component, massive loss of bone stock of proximal femur, acetabular protrusion and a consequent pelvic discontinuity. Clinically, a completely disfunctional left hip joint was registered (Harris hip score--7.1). We performed total rearthroplasty by a custom-made Waldemar Link total hip prosthesis with acetabular antiprotrusio cage and compensation of bone defects with a graft from the bone bank. A year after the operation, we found clinically an extreme improvement in Harris hip score--87.8. Radiographically, we found stability of implanted components, a complete graft integration and bone bridging across the site of pelvic discontinuity. Pelvic discontinuity and massive loss of proximal femoral bone stock is a challenging and complex entity. Conventional prostheses cannot provide an adequate fixation and stability of the hip. Application of custom-made prosthesis (measured specificaly for a patient) and additional alografting bone defects is a good method in revision surgery after unsuccessful hip arthroplasty with extensive bone defects.

Incremental validity of estimated cannabis grams as a predictor of problems and cannabinoid biomarkers: Evidence from a clinical trial.

PubMed

Tomko, Rachel L; Baker, Nathaniel L; McClure, Erin A; Sonne, Susan C; McRae-Clark, Aimee L; Sherman, Brian J; Gray, Kevin M

2018-01-01

Quantifying cannabis use is complex due to a lack of a standardized packaging system that contains specified amounts of constituents. A laboratory procedure has been developed for estimating physical quantity of cannabis use by utilizing a surrogate substance to represent cannabis, and weighing the amount of the surrogate to determine typical use in grams. This secondary analysis utilized data from a multi-site, randomized, controlled pharmacological trial for adult cannabis use disorder (N=300), sponsored by the National Drug Abuse Treatment Clinical Trials Network, to test the incremental validity of this procedure. In conjunction with the Timeline Followback, this physical scale-based procedure was used to determine whether average grams per cannabis administration predicted urine cannabinoid levels (11-nor-9-carboxy-Δ9-tetrahydrocannabinol) and problems due to use, after accounting for self-reported number of days used (in the past 30 days) and number of administrations per day in a 12-week clinical trial for cannabis use disorder. Likelihood ratio tests suggest that model fit was significantly improved when grams per administration and relevant interactions were included in the model predicting urine cannabinoid level (X 2 =98.3; p<0.05) and in the model predicting problems due to cannabis use (X 2 =6.4; p<0.05), relative to a model that contained only simpler measures of quantity and frequency. This study provides support for the use of a scale-based method for quantifying cannabis use in grams. This methodology may be useful when precise quantification is necessary (e.g., measuring reduction in use in a clinical trial). Copyright © 2017 Elsevier B.V. All rights reserved.

Preparing for Complexity and Wicked Problems through Transformational Learning Approaches

ERIC Educational Resources Information Center

Yukawa, Joyce

2015-01-01

As the information environment becomes increasingly complex and challenging, Library and Information Studies (LIS) education is called upon to nurture innovative leaders capable of managing complex situations and "wicked problems." While disciplinary expertise remains essential, higher levels of mental complexity and adaptive…

Natural head position: An overview.

PubMed

Meiyappan, N; Tamizharasi, S; Senthilkumar, K P; Janardhanan, K

2015-08-01

Cephalometrics has given us a different perspective of interpreting various skeletal problems in the dentofacial complex. Natural head position (NHP) is a reproducible, physiologically determined aspect of function. To determine NHP, a horizontal or vertical reference line outside the crania was used, but preference was given generally to the horizontal. Various intra and extracranial cephalometric horizontal reference planes have been used to formulate diagnosis and plan individualized treatment for an integrated correction of the malocclusion cephalometrics is constantly undergoing refinements in its techniques and analyses to improve the clinical applications. Even though various methods for establishing NHP have been proposed, still it remains a challenge to the clinicians to implement the concept of NHP thoroughly in all the stages of treatment because of practical difficulties in the clinical scenario.

Complexity in Nature and Society: Complexity Management in the Age of Globalization

NASA Astrophysics Data System (ADS)

Mainzer, Klaus

The theory of nonlinear complex systems has become a proven problem-solving approach in the natural sciences from cosmic and quantum systems to cellular organisms and the brain. Even in modern engineering science self-organizing systems are developed to manage complex networks and processes. It is now recognized that many of our ecological, social, economic, and political problems are also of a global, complex, and nonlinear nature. What are the laws of sociodynamics? Is there a socio-engineering of nonlinear problem solving? What can we learn from nonlinear dynamics for complexity management in social, economic, financial and political systems? Is self-organization an acceptable strategy to handle the challenges of complexity in firms, institutions and other organizations? It is a main thesis of the talk that nature and society are basically governed by nonlinear and complex information dynamics. How computational is sociodynamics? What can we hope for social, economic and political problem solving in the age of globalization?.

The Role of Automatic Negative Reinforcement in Clinical Problems

ERIC Educational Resources Information Center

Miltenberger, Raymond G.

2005-01-01

This paper discusses the role of automatic negative reinforcement in the maintenance of clinical problems. Following a brief introduction to the functional conceptualization of clinical problems and discussion of four classes of reinforcement maintaining clinical problems, the paper suggests that automatic negative reinforcement is an understudied…

Clinical Complexity in Medicine: A Measurement Model of Task and Patient Complexity.

PubMed

Islam, R; Weir, C; Del Fiol, G

2016-01-01

Complexity in medicine needs to be reduced to simple components in a way that is comprehensible to researchers and clinicians. Few studies in the current literature propose a measurement model that addresses both task and patient complexity in medicine. The objective of this paper is to develop an integrated approach to understand and measure clinical complexity by incorporating both task and patient complexity components focusing on the infectious disease domain. The measurement model was adapted and modified for the healthcare domain. Three clinical infectious disease teams were observed, audio-recorded and transcribed. Each team included an infectious diseases expert, one infectious diseases fellow, one physician assistant and one pharmacy resident fellow. The transcripts were parsed and the authors independently coded complexity attributes. This baseline measurement model of clinical complexity was modified in an initial set of coding processes and further validated in a consensus-based iterative process that included several meetings and email discussions by three clinical experts from diverse backgrounds from the Department of Biomedical Informatics at the University of Utah. Inter-rater reliability was calculated using Cohen's kappa. The proposed clinical complexity model consists of two separate components. The first is a clinical task complexity model with 13 clinical complexity-contributing factors and 7 dimensions. The second is the patient complexity model with 11 complexity-contributing factors and 5 dimensions. The measurement model for complexity encompassing both task and patient complexity will be a valuable resource for future researchers and industry to measure and understand complexity in healthcare.

Word problems: a review of linguistic and numerical factors contributing to their difficulty

PubMed Central

Daroczy, Gabriella; Wolska, Magdalena; Meurers, Walt Detmar; Nuerk, Hans-Christoph

2015-01-01

Word problems (WPs) belong to the most difficult and complex problem types that pupils encounter during their elementary-level mathematical development. In the classroom setting, they are often viewed as merely arithmetic tasks; however, recent research shows that a number of linguistic verbal components not directly related to arithmetic contribute greatly to their difficulty. In this review, we will distinguish three components of WP difficulty: (i) the linguistic complexity of the problem text itself, (ii) the numerical complexity of the arithmetic problem, and (iii) the relation between the linguistic and numerical complexity of a problem. We will discuss the impact of each of these factors on WP difficulty and motivate the need for a high degree of control in stimuli design for experiments that manipulate WP difficulty for a given age group. PMID:25883575

Mobile technology supporting trainee doctors' workplace learning and patient care: an evaluation.

PubMed

Hardyman, Wendy; Bullock, Alison; Brown, Alice; Carter-Ingram, Sophie; Stacey, Mark

2013-01-21

The amount of information needed by doctors has exploded. The nature of knowledge (explicit and tacit) and processes of knowledge acquisition and participation are complex. Aiming to assist workplace learning, Wales Deanery funded "iDoc", a project offering trainee doctors a Smartphone library of medical textbooks. Data on trainee doctors' (Foundation Year 2) workplace information seeking practice was collected by questionnaire in 2011 (n = 260). iDoc baseline questionnaires (n = 193) collected data on Smartphone usage alongside other workplace information sources. Case reports (n = 117) detail specific instances of Smartphone use. Most frequently (daily) used information sources in the workplace: senior medical staff (80% F2 survey; 79% iDoc baseline); peers (70%; 58%); and other medical/nursing team staff (53% both datasets). Smartphones were used more frequently by males (p < 0.01). Foundation Year 1 (newly qualified) was judged the most useful time to have a Smartphone library because of increased responsibility and lack of knowledge/experience.Preferred information source varied by question type: hard copy texts for information-based questions; varied resources for skills queries; and seniors for more complex problems. Case reports showed mobile technology used for simple (information-based), complex (problem-based) clinical questions and clinical procedures (skills-based scenarios). From thematic analysis, the Smartphone library assisted: teaching and learning from observation; transition from medical student to new doctor; trainee doctors' discussions with seniors; independent practice; patient care; and this 'just-in-time' access to reliable information supported confident and efficient decision-making. A variety of information sources are used regularly in the workplace. Colleagues are used daily but seniors are not always available. During transitions, constant access to the electronic library was valued. It helped prepare trainee doctors for discussions with their seniors, assisting the interchange between explicit and tacit knowledge.By supporting accurate prescribing and treatment planning, the electronic library contributed to enhanced patient care. Trainees were more rapidly able to medicate patients to reduce pain and more quickly call for specific assessments. However, clinical decision-making often requires dialogue: what Smartphone technology can do is augment, not replace, discussion with their colleagues in the community of practice.

New Insights into Clinical Characteristics of Gilles de la Tourette Syndrome: Findings in 1032 Patients from a Single German Center.

PubMed

Sambrani, Tanvi; Jakubovski, Ewgeni; Müller-Vahl, Kirsten R

2016-01-01

Gilles de la Tourette syndrome (TS) is a complex neuropsychiatric disorder defined by the presence of motor and phonic tics, but often associated with psychiatric comorbidities. The main objective of this study was to explore the clinical presentation and comorbidities of TS. We analyzed clinical data obtained from a large sample (n = 1032; 529 children and 503 adults) of patients with tic disorders from one single German TS center assessed by one investigator. Data was collected with the help of an expert-reviewed semi-structured interview, designed to assess tic severity and certain comorbidities. Group comparisons were carried out via independent sample t-tests and chi-square tests. The main findings of the study are: (1) tic severity is associated with the presence of premonitory urges (PU), copro-, echo-, and paliphenomena and the number of comorbidities, but not age at tic onset; it is higher in patients with comorbid obsessive-compulsive disorder (OCD) than in patients with comorbid attention deficit/hyperactivity disorder (ADHD). (2) PU were found to be highly associated with "not just right experiences" and to emerge much earlier than previously thought alongside with the ability to suppress tics (PU in >60% and suppressibility in >75% at age 8-10 years). (3) Self-injurious behavior (SIB) is highly associated with complex motor tics and coprophenomena, but not with OCD/obsessive-compulsive behavior (OCB). While comorbid ADHD is associated with a lower ability to suppress tics, comorbid depression is associated with sleeping problems. Our results demonstrate that tic severity is not influenced by age at onset. From our data, it is suggested that PU represent a specific type of "not just right experience" that is not a prerequisite for tic suppression. Comorbid ADHD reduces patients' ability of successful tic suppression. Our data suggest that SIB belongs to the coprophenomena spectrum and hence should be conceptualized as a complex tic rather than a compulsion. Finally, this study strongly supports the hypothesis that TS+OCD is a more severe form of TS and that comorbid OCD/OCB, depression, and anxiety belong to the TS spectrum, while ADHD should be better conceptualized as a separate problem.

Financial impact of tertiary care in an academic medical center.

PubMed

Huber, T S; Carlton, L M; O'Hern, D G; Hardt, N S; Keith Ozaki, C; Flynn, T C; Seeger, J M

2000-06-01

To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Stabilizing l1-norm prediction models by supervised feature grouping.

PubMed

Kamkar, Iman; Gupta, Sunil Kumar; Phung, Dinh; Venkatesh, Svetha

2016-02-01

Emerging Electronic Medical Records (EMRs) have reformed the modern healthcare. These records have great potential to be used for building clinical prediction models. However, a problem in using them is their high dimensionality. Since a lot of information may not be relevant for prediction, the underlying complexity of the prediction models may not be high. A popular way to deal with this problem is to employ feature selection. Lasso and l1-norm based feature selection methods have shown promising results. But, in presence of correlated features, these methods select features that change considerably with small changes in data. This prevents clinicians to obtain a stable feature set, which is crucial for clinical decision making. Grouping correlated variables together can improve the stability of feature selection, however, such grouping is usually not known and needs to be estimated for optimal performance. Addressing this problem, we propose a new model that can simultaneously learn the grouping of correlated features and perform stable feature selection. We formulate the model as a constrained optimization problem and provide an efficient solution with guaranteed convergence. Our experiments with both synthetic and real-world datasets show that the proposed model is significantly more stable than Lasso and many existing state-of-the-art shrinkage and classification methods. We further show that in terms of prediction performance, the proposed method consistently outperforms Lasso and other baselines. Our model can be used for selecting stable risk factors for a variety of healthcare problems, so it can assist clinicians toward accurate decision making. Copyright © 2015 Elsevier Inc. All rights reserved.

How Cognitive Style and Problem Complexity Affect Preservice Agricultural Education Teachers' Abilities to Solve Problems in Agricultural Mechanics

ERIC Educational Resources Information Center

Blackburn, J. Joey; Robinson, J. Shane; Lamm, Alexa J.

2014-01-01

The purpose of this experimental study was to determine the effects of cognitive style and problem complexity on Oklahoma State University preservice agriculture teachers' (N = 56) ability to solve problems in small gasoline engines. Time to solution was operationalized as problem solving ability. Kirton's Adaption-Innovation Inventory was…

On the Complexity of Delaying an Adversary’s Project

DTIC Science & Technology

2005-01-01

interdiction models for such problems and show that the resulting problem com- plexities run the gamut : polynomially solvable, weakly NP-complete, strongly...problems and show that the resulting problem complexities run the gamut : polynomially solvable, weakly NP-complete, strongly NP-complete or NP-hard. We

Solving the Inverse-Square Problem with Complex Variables

ERIC Educational Resources Information Center

Gauthier, N.

2005-01-01

The equation of motion for a mass that moves under the influence of a central, inverse-square force is formulated and solved as a problem in complex variables. To find the solution, the constancy of angular momentum is first established using complex variables. Next, the complex position coordinate and complex velocity of the particle are assumed…

Temporal data representation, normalization, extraction, and reasoning: A review from clinical domain

PubMed Central

Madkour, Mohcine; Benhaddou, Driss; Tao, Cui

2016-01-01

Background and Objective We live our lives by the calendar and the clock, but time is also an abstraction, even an illusion. The sense of time can be both domain-specific and complex, and is often left implicit, requiring significant domain knowledge to accurately recognize and harness. In the clinical domain, the momentum gained from recent advances in infrastructure and governance practices has enabled the collection of tremendous amount of data at each moment in time. Electronic Health Records (EHRs) have paved the way to making these data available for practitioners and researchers. However, temporal data representation, normalization, extraction and reasoning are very important in order to mine such massive data and therefore for constructing the clinical timeline. The objective of this work is to provide an overview of the problem of constructing a timeline at the clinical point of care and to summarize the state-of-the-art in processing temporal information of clinical narratives. Methods This review surveys the methods used in three important area: modeling and representing of time, Medical NLP methods for extracting time, and methods of time reasoning and processing. The review emphasis on the current existing gap between present methods and the semantic web technologies and catch up with the possible combinations. Results the main findings of this review is revealing the importance of time processing not only in constructing timelines and clinical decision support systems but also as a vital component of EHR data models and operations. Conclusions Extracting temporal information in clinical narratives is a challenging task. The inclusion of ontologies and semantic web will lead to better assessment of the annotation task and, together with medical NLP techniques, will help resolving granularity and co-reference resolution problems. PMID:27040831

The design and development of a complex multifactorial falls assessment intervention for falls prevention: The Prevention of Falls Injury Trial (PreFIT).

PubMed

Bruce, Julie; Ralhan, Shvaita; Sheridan, Ray; Westacott, Katharine; Withers, Emma; Finnegan, Susanne; Davison, John; Martin, Finbarr C; Lamb, Sarah E

2017-06-01

This paper describes the design and development of a complex multifactorial falls prevention (MFFP) intervention for implementation and testing within the framework of a large UK-based falls prevention randomised controlled trial (RCT). A complex intervention was developed for inclusion within the Prevention of Falls Injury Trial (PreFIT), a multicentre pragmatic RCT. PreFIT aims to compare the clinical and cost-effectiveness of three alternative primary care falls prevention interventions (advice, exercise and MFFP), on outcomes of fractures and falls. Community-dwelling adults, aged 70 years and older, were recruited from primary care in the National Health Service (NHS), England. Development of the PreFIT MFFP intervention was informed by the existing evidence base and clinical guidelines for the assessment and management of falls in older adults. After piloting and modification, the final MFFP intervention includes seven falls risk factors: a detailed falls history interview with consideration of 'red flags'; assessment of balance and gait; vision; medication screen; cardiac screen; feet and footwear screen and home environment assessment. This complex intervention has been fully manualised with clear, documented assessment and treatment pathways for each risk factor. Each risk factor is assessed in every trial participant referred for MFFP. Referral for assessment is based upon a screening survey to identify those with a history of falling or balance problems. Intervention delivery can be adapted to the local setting. This complex falls prevention intervention is currently being tested within the framework of a large clinical trial. This paper adheres to TIDieR and CONSORT recommendations for the comprehensive and explicit reporting of trial interventions. Results from the PreFIT study will be published in due course. The effectiveness and cost-effectiveness of the PreFIT MFFP intervention, compared to advice and exercise, on the prevention of falls and fractures, will be reported at the conclusion of the trial.

Context matters when striving to promote active and lifelong learning in medical education.

PubMed

Berkhout, Joris J; Helmich, Esther; Teunissen, Pim W; van der Vleuten, Cees P M; Jaarsma, A Debbie C

2018-01-01

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts. Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

The laboratory workforce shortage: a managerial perspective.

PubMed

Cortelyou-Ward, Kendall; Ramirez, Bernardo; Rotarius, Timothy

2011-01-01

Most clinical laboratories in the nation report severe difficulties in recruitment and retention of most types of personnel. Other important factors impacting this problem include work complexities, increased automation, and a graying workforce. As a further challenge, institutional needs for clinical laboratory personnel are expected to grow significantly in the next decade. This article examines the current situation of the clinical laboratory workforce. It analyzes the different types of personnel; the managerial, supervision, and line positions that are key for different types of laboratories; the job outlook and recent projections for different types of staff; and the current issues, trends, and challenges of the laboratory workforce. Laboratory managers need to take action with strategies suggested for overcoming these challenges. Most importantly, they need to become transformational leaders by developing effective staffing models, fostering healthy and productive work environments, and creating value with a strategic management culture and implementation of knowledge management.

Organization and management of community-based dental education programs: an overview from the dental Pipeline program.

PubMed

Bailit, Howard L

2010-10-01

Disparities in access to dental care are a major problem in the United States. Effectively run community-based dental education programs can make a significant contribution to reducing access disparities and at the same time enrich the educational experiences of dental students and residents. For complex historical reasons, dental schools did not base their clinical training programs in community hospitals and clinics like the other health professions. Now, because of trends in school finances, changes in societal values, and limitations in current educational experiences, schools are increasing the time students spend in community clinics. This is likely to continue. The chapters in the first section of the report on the Pipeline, Profession, and Practice: Community-Based Dental Education program--for which this chapter serves as an introduction-provide detailed information on the operation of community-based education programs.

[Public health, genetics and ethics].

PubMed

Kottow, Miguel H

2002-10-01

Genetics research has shown enormous developments in recent decades, although as yet with only limited clinical application. Bioethical analysis has been unable to deal with the vast problems of genetics because emphasis has been put on the principlism applied to both clinical and research bioethics. Genetics nevertheless poses its most complex moral dilemmas at the public level, where a social brand of ethics ought to supersede the essentially interpersonal perspective of principlism. A more social understanding of ethics in genetics is required to unravel issues such as research and clinical explorations, ownership and patents, genetic manipulation, and allocation of resources. All these issues require reflection based on the requirements of citizenry, consideration of common assets, and definition of public policies in regulating genetic endeavors and protecting the society as a whole Bioethics has privileged the approach to individual ethical issues derived from genetic intervention, thereby neglecting the more salient aspects of genetics and social ethics.

Clinical innovation for promoting family care in paediatric intensive care: demonstration, role modelling and reflective practice.

PubMed

Tomlinson, Patricia S; Thomlinson, Elizabeth; Peden-McAlpine, Cynthia; Kirschbaum, Mark

2002-04-01

To explore family caregiving problems in paediatric crisis care and methods that could be applied to move the abstraction of family care to development of specific family interventions. Family centred care has been accepted as the ideal philosophy for holistic health care of children, but methods for its implementation are not well established. In paediatric health crises, family care requires special sensitivity to family needs and a type of complex nursing care for which many practitioners are not sufficiently prepared. Developing family sensitive models of intervention and finding a strategy for transfer of this knowledge to clinical practice is an important challenge facing family nursing today. Social learning theory provides a rich background to explore these issues. Specific techniques of role modelling and reflective practice are suggested as effective approaches to teach family sensitive care in clinical settings where families are part of the care environment.

SEMCARE: Multilingual Semantic Search in Semi-Structured Clinical Data.

PubMed

López-García, Pablo; Kreuzthaler, Markus; Schulz, Stefan; Scherr, Daniel; Daumke, Philipp; Markó, Kornél; Kors, Jan A; van Mulligen, Erik M; Wang, Xinkai; Gonna, Hanney; Behr, Elijah; Honrado, Ángel

2016-01-01

The vast amount of clinical data in electronic health records constitutes a great potential for secondary use. However, most of this content consists of unstructured or semi-structured texts, which is difficult to process. Several challenges are still pending: medical language idiosyncrasies in different natural languages, and the large variety of medical terminology systems. In this paper we present SEMCARE, a European initiative designed to minimize these problems by providing a multi-lingual platform (English, German, and Dutch) that allows users to express complex queries and obtain relevant search results from clinical texts. SEMCARE is based on a selection of adapted biomedical terminologies, together with Apache UIMA and Apache Solr as open source state-of-the-art natural language pipeline and indexing technologies. SEMCARE has been deployed and is currently being tested at three medical institutions in the UK, Austria, and the Netherlands, showing promising results in a cardiology use case.

Refusing the cure: Sophocles's Philoctetes and the clinical problems of self-injurious spite, shame and forgiveness.

PubMed

Gottlieb, Richard M

2004-06-01

Sophocles's Philoctetes (409 BCE) is a dramatic masterpiece unfamiliar to most analysts. The play presents a complex portrait of self-injurious spite of heroic dimensions as it touches on issues of intense shame, feelings of helplessness and the refusal of forgiveness. Sophocles's protagonist, Philoctetes, is a man who, like some of our patients, refuses to be healed. He intends, through his continued sickness and misery, to exact revenge against those who mistreated him. These are recognizable clinical issues, playing roles in every psychoanalytic treatment, issues that may assume a special importance in protracted, stalemated or aborted analyses. There are patients who damage the analyst by damaging the analysis they are in, a malevolent project often undertaken in revenge for wrongs suffered during childhood. This paper links Sophocles's drama to these vitally important clinical considerations through the discussion of a particular case.

Dashboard systems: Pharmacokinetic/pharmacodynamic mediated dose optimization for monoclonal antibodies.

PubMed

Mould, Diane R; Dubinsky, Marla C

2015-03-01

Many marketed drugs exhibit high variability in exposure and response. While these drugs are efficacious in their approved indications, finding appropriate dose regimens for individual patients is not straightforward. Similar dose adjustment problems are also seen with drugs that have a complex relationship between exposure and response and/or a narrow therapeutic window. This is particularly true for monoclonal antibodies, where prolonged dosing at a sub-therapeutic dose can also elicit anti-drug antibodies which will further compromise safety and efficacy. Thus, finding appropriate doses quickly would represent a substantial improvement in healthcare. Dashboard systems, which are decision-support tools, offer an improved, convenient means of tailoring treatment for individual patients. This article reviews the clinical need for this approach, particularly with monoclonal antibodies, the design, development, and testing of such systems, and the likely benefits of dashboard systems in clinical practice. We focus on infliximab for reference. © 2015, The American College of Clinical Pharmacology.

Gilles de la Tourette syndrome as a paradigmatic neuropsychiatric disorder.

PubMed

Cavanna, Andrea E

2018-05-21

Gilles de la Tourette syndrome is a chronic and complex tic disorder accompanied by specific behavioral problems in the majority of patients. With its multifaceted interplay between motion and emotion, this condition is a paradigmatic example of the science and art of clinical neuropsychiatry. This review article encompasses the clinical phenomenology of motor and vocal tics and associated sensory experiences (premonitory urges), as well as the behavioral spectrum of the most common comorbidities, including obsessive-compulsive disorder, attention-deficit and hyperactivity disorder, affective symptoms, and impulsivity. Knowledge of the contributions of both tics and behavioral problems to patients' health-related quality of life across the lifespan should assist treating clinicians in formulating a targeted management plan. Although the exact pathophysiology of Gilles de la Tourette syndrome remains elusive, research into therapeutic interventions has expanded the range of available interventions across multiple domains. A thorough understanding of the neurology and psychiatry of this condition is of key importance to meet the needs of this patient population, from the formulation of an accurate diagnosis to the implementation of effective treatment strategies.

Nonrigid Image Registration in Digital Subtraction Angiography Using Multilevel B-Spline

PubMed Central

2013-01-01

We address the problem of motion artifact reduction in digital subtraction angiography (DSA) using image registration techniques. Most of registration algorithms proposed for application in DSA, have been designed for peripheral and cerebral angiography images in which we mainly deal with global rigid motions. These algorithms did not yield good results when applied to coronary angiography images because of complex nonrigid motions that exist in this type of angiography images. Multiresolution and iterative algorithms are proposed to cope with this problem, but these algorithms are associated with high computational cost which makes them not acceptable for real-time clinical applications. In this paper we propose a nonrigid image registration algorithm for coronary angiography images that is significantly faster than multiresolution and iterative blocking methods and outperforms competing algorithms evaluated on the same data sets. This algorithm is based on a sparse set of matched feature point pairs and the elastic registration is performed by means of multilevel B-spline image warping. Experimental results with several clinical data sets demonstrate the effectiveness of our approach. PMID:23971026

Recruitment and Retention of Older Adults in Aging Research

PubMed Central

Mody, Lona; Miller, Douglas K.; McGloin, Joanne M.; Div, M; Freeman, Marcie; Marcantonio, Edward R.; Magaziner, Jay; Studenski, Stephanie

2009-01-01

Older adults continue to be underrepresented in clinical research despite their burgeoning population in the United States and worldwide. Physicians often propose treatment plans for older adults based on data from studies involving primarily younger, more-functional, healthier participants. Major barriers to recruitment of older adults in aging research relate to their substantial health problems, social and cultural barriers, and potentially impaired capacity to provide informed consent. Institutionalized older adults offer another layer of complexity that requires cooperation from the institutions to participate in research activities. This paper provides study recruitment and retention techniques and strategies to address concerns and overcome barriers to older adult participation in clinical research. Key approaches include early in-depth planning; minimizing exclusion criteria; securing cooperation from all interested parties; using advisory boards, timely screening, identification, and approach of eligible patients; carefully reviewing the benefit:risk ratio to be sure it is appropriate; and employing strategies to ensure successful retention across the continuum of care. Targeting specific strategies to the condition, site, and population of interest and anticipating potential problems and promptly employing predeveloped contingency plans are keys to effective recruitment and retention. PMID:19093934

Financial issues constraining the use of pancreata recovered for islet transplantation: a white paper.

PubMed

Markmann, J F; Kaufman, D B; Ricordi, C; Schwab, P M; Stock, P G

2008-08-01

Islet transplantation is a very promising therapy for select patients with type 1 diabetes. Continued clinical investigation is required to define the long-term safety and efficacy outcomes before the procedure will be accepted as a standard of care even for those with the most severe manifestations of diabetes. Threatening successful accomplishment of these and other innovative studies designed to advance the field are the complex financial cost accounting issues that pose undue burden on organ procurement organizations and transplant centers trying to manage the costs of the pancreata from deceased donors needed to isolate islets. Compounding the problem is the recent ruling by CMS regarding 'intent to transplant' (CMS-1543-R Dec. 21, 2006: Allocation of Donor Acquisition Costs Incurred by Organ Procurement Organizations) that does not account for the clinical need to complete the manufacturing process for islets before suitability and transplant intent of the pancreata involved can be determined. We provide a consensus document supported by a diverse group of stakeholders in islet transplantation to suggest actions to address this problem.

Posture and Locomotion Coupling: A Target for Rehabilitation Interventions in Persons with Parkinson's Disease

PubMed Central

Mille, Marie-Laure; Creath, Robert A.; Prettyman, Michelle G.; Johnson Hilliard, Marjorie; Martinez, Katherine M.; MacKinnon, Colum D.; Rogers, Mark W.

2012-01-01

Disorders of posture, balance, and gait are debilitating motor manifestations of advancing Parkinson's disease requiring rehabilitation intervention. These problems often reflect difficulties with coupling or sequencing posture and locomotion during complex whole body movements linked with falls. Considerable progress has been made with demonstrating the effectiveness of exercise interventions for individuals with Parkinson's disease. However, gaps remain in the evidence base for specific interventions and the optimal content of exercise interventions. Using a conceptual theoretical framework and experimental findings, this perspective and review advances the viewpoint that rehabilitation interventions focused on separate or isolated components of posture, balance, or gait may limit the effectiveness of current clinical practices. It is argued that treatment effectiveness may be improved by directly targeting posture and locomotion coupling problems as causal factors contributing to balance and gait dysfunction. This approach may help advance current clinical practice and improve outcomes in rehabilitation for persons with Parkinson's disease. “. . .postural activity should be regarded as a function in its own right and not merely as a component of movement. . .” James Purdon Martin PMID:22295253

Dynamic Modeling as a Cognitive Regulation Scaffold for Developing Complex Problem-Solving Skills in an Educational Massively Multiplayer Online Game Environment

ERIC Educational Resources Information Center

Eseryel, Deniz; Ge, Xun; Ifenthaler, Dirk; Law, Victor

2011-01-01

Following a design-based research framework, this article reports two empirical studies with an educational MMOG, called "McLarin's Adventures," on facilitating 9th-grade students' complex problem-solving skill acquisition in interdisciplinary STEM education. The article discusses the nature of complex and ill-structured problem solving…

You Need to Know: There Is a Causal Relationship between Structural Knowledge and Control Performance in Complex Problem Solving Tasks

ERIC Educational Resources Information Center

Goode, Natassia; Beckmann, Jens F.

2010-01-01

This study investigates the relationships between structural knowledge, control performance and fluid intelligence in a complex problem solving (CPS) task. 75 participants received either complete, partial or no information regarding the underlying structure of a complex problem solving task, and controlled the task to reach specific goals.…

Pre-Service Teachers' Free and Structured Mathematical Problem Posing

ERIC Educational Resources Information Center

Silber, Steven; Cai, Jinfa

2017-01-01

This exploratory study examined how pre-service teachers (PSTs) pose mathematical problems for free and structured mathematical problem-posing conditions. It was hypothesized that PSTs would pose more complex mathematical problems under structured posing conditions, with increasing levels of complexity, than PSTs would pose under free posing…

With nurse practitioners, who needs house officers?

PubMed Central

Dowling, S.; Barrett, S.; West, R.

1995-01-01

The boundaries between the work of doctors and that of nurses are changing, with nurses taking over important parts of junior hospital doctors' clinical work. In 1993 an exploratory study was carried out to identify the professional, educational, and management issues that such developments raise. Interviews were carried out with a range of stakeholders in three innovatory posts in which nurses were doing much of the clinical work of house officers. A complex picture of perceived benefits and problems for patients, junior doctors, and nurses emerged. These seemed to be associated with (a) the extent to which the contribution of professional nursing was valued in the new role and (b) the amount of clinical discretion which the postholder was allowed, this depending on the type of preparatory education provided and the management of the post. The study points to the need for strategic issues--such as the development of appropriate education and the professional recognition of these new clinical roles--to be addressed at a national and regional level. Images p312-a PMID:7633246

Case Mis-Conceptualization in Psychological Treatment: An Enduring Clinical Problem.

PubMed

Ridley, Charles R; Jeffrey, Christina E; Roberson, Richard B

2017-04-01

Case conceptualization, an integral component of mental health treatment, aims to facilitate therapeutic gains by formulating a clear picture of a client's psychological presentation. However, despite numerous attempts to improve this clinical activity, it remains unclear how well existing methods achieve their purported purpose. Case formulation is inconsistently defined in the literature and implemented in practice, with many methods varying in complexity, theoretical grounding, and empirical support. In addition, many of the methods demand a precise clinical acumen that is easily influenced by judgmental and inferential errors. These errors occur regardless of clinicians' level of training or amount of clinical experience. Overall, the lack of a consensus definition, a diversity of methods, and susceptibility of clinicians to errors are manifestations of the state of crisis in case conceptualization. This article, the 2nd in a series of 5 on thematic mapping, argues the need for more reliable and valid models of case conceptualization. © 2017 Wiley Periodicals, Inc.

MODELS OF INSULIN RESISTANCE AND HEART FAILURE

PubMed Central

Velez, Mauricio; Kohli, Smita; Sabbah, Hani N.

2013-01-01

The incidence of heart failure (HF) and diabetes mellitus is rapidly increasing and is associated with poor prognosis. In spite of the advances in therapy, HF remains a major health problem with high morbidity and mortality. When HF and diabetes coexist, clinical outcomes are significantly worse. The relationship between these two conditions has been studied in various experimental models. However, the mechanisms for this interrelationship are complex, incompletely understood, and have become a matter of considerable clinical and research interest. There are only few animal models that manifest both HF and diabetes. However, the translation of results from these models to human disease is limited and new models are needed to expand our current understanding of this clinical interaction. In this review, we discuss mechanisms of insulin signaling and insulin resistance, the clinical association between insulin resistance and HF and its proposed pathophysiologic mechanisms. Finally, we discuss available animal models of insulin resistance and HF and propose requirements for future new models. PMID:23456447

An Approach to Management of Gas in the Elderly

PubMed Central

Hogan, David B.

1989-01-01

In this article I shall review the physiology, clinical manifestations, and management of gaseousness in the elderly. While not an infrequent complaint, little scientific study has been done of the causes or management of this problem. The regualtion of bowel gas is surprisingly complex. When problems occur, it is usually either because of excessive swallowing of air or because of the intraluminal producation of gas by colonic bacteria. Patients present with excessive belching, abdominal pain and bloating, or excessive passage of flatus. Management is determined, in the main, by the results of the history and physical examination. Medications are usually not indicated. Once a malabsorptive state is ruled out, the mainstay of management usually involves either alterations in the patient's diet or avoidance of aerophagia. PMID:21249002

Posttraumatic Stress Disorder and Co-Occurring Substance Use Disorders: Advances in Assessment and Treatment

PubMed Central

McCauley, Jenna L; Killeen, Therese; Gros, Daniel F.; Brady, Kathleen T.; Back, Sudie E.

2013-01-01

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) are prevalent and frequently co-occur. Comorbid PTSD/SUD is associated with a more complex and costly clinical course when compared with either disorder alone, including increased chronic physical health problems, poorer social functioning, higher rates of suicide attempts, more legal problems, increased risk of violence, worse treatment adherence, and less improvement during treatment. In response, psychosocial treatment options have increased substantially over the past decade and integrated approaches – treatments that address symptoms of both PTSD and SUD concurrently –are fast becoming the preferred model for treatment. This paper reviews the prevalence, etiology and assessment practices as well as advances in the behavioral and pharmacologic treatment of comorbid PTSD and SUDs. PMID:24179316

Translational Cognition for Decision Support in Critical Care Environments: A Review

PubMed Central

Patel, Vimla L.; Zhang, Jiajie; Yoskowitz, Nicole A.; Green, Robert; Sayan, Osman R.

2008-01-01

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers. PMID:18343731

Translational cognition for decision support in critical care environments: a review.

PubMed

Patel, Vimla L; Zhang, Jiajie; Yoskowitz, Nicole A; Green, Robert; Sayan, Osman R

2008-06-01

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real-world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers.

Medical education: part of the problem and part of the solution.

PubMed

Lucey, Catherine Reinis

2013-09-23

Medical education today is pedagogically superb, but the graduates of our educational programs are still unable to successfully translate decades of biomedical advances into health care that reliably meets the Institute of Medicine quality criteria. Realizing the promise of high-quality health care will require that medical educators accept that they must fulfill their contract with society to reduce the burden of suffering and disease through the education of physicians. Educational redesign must begin with the understanding that the professional identity of the physician who was successful in the acute disease era of the 20th century will not be effective in the complex chronic disease era of the 21st century. Medical schools and residency programs must restructure their views of basic and clinical science and workplace learning to give equal emphasis to the science and skills needed to practice in and lead in complex systems. They must also rethink their relationships with clinical environments so that the education of students and residents accelerates the transformation in health care delivery needed to fulfill our contract with society.

[Social trauma: Clinical practice and analysis of subjectivity].

PubMed

Lagos, Mariana; Bekerman, Silvana; Sosa, Noemí

2017-07-01

Clinical and psychosocial assistance demand that we try and understand the complex effect traumatic events have on people and their subjectivity, as well as on our own stance and reference framework. Traumatic situations of social origin affect groups of individuals and the State is to some extent responsible for their genesis and the resolution of their effects. In our professional practice we are faced with problems that concern both the individuals and the relationships they establish. The way highly traumatic events are dealt with is in?uenced by various factors that challenge our therapeutic theories and approaches. The crisis of our time, characterized by uncertainty, violence patterns, intolerance of differences, fracture of social bonds, combined with major technological developments and subjective changes, triggers new and complex ways of connection -even hyperconnectivity- through social media. These vicissitudes of our time confront us with new expressions of discomfort about our own place in the world, deeply affect our identities and reinforce the suffering we experience when faced with the emergency of the devastating power of social trauma. Thus, they become part of our current challenge as professionals.

Leigh and Leigh-like syndrome in children and adults.

PubMed

Finsterer, Josef

2008-10-01

Leigh syndrome (also termed subacute, necrotizing encephalopathy) is a devastating neurodegenerative disorder, characterized by almost identical brain changes, e.g., focal, bilaterally symmetric lesions, particularly in the basal ganglia, thalamus, and brainstem, but with considerable clinical and genetic heterogeneity. Clinically, Leigh syndrome is characterized by a wide variety of abnormalities, from severe neurologic problems to a near absence of abnormalities. Most frequently the central nervous system is affected, with psychomotor retardation, seizures, nystagmus, ophthalmoparesis, optic atrophy, ataxia, dystonia, or respiratory failure. Some patients also present with peripheral nervous system involvement, including polyneuropathy or myopathy, or non-neurologic abnormalities, e.g., diabetes, short stature, hypertrichosis, cardiomyopathy, anemia, renal failure, vomiting, or diarrhea (Leigh-like syndrome). In the majority of cases, onset is in early childhood, but in a small number of cases, adults are affected. In the majority of cases, dysfunction of the respiratory chain (particularly complexes I, II, IV, or V), of coenzyme Q, or of the pyruvate dehydrogenase complex are responsible for the disease. Associated mutations affect genes of the mitochondrial or nuclear genome. Leigh syndrome and Leigh-like syndrome are the mitochondrial disorders with the largest genetic heterogeneity.

A restricted Steiner tree problem is solved by Geometric Method II

NASA Astrophysics Data System (ADS)

Lin, Dazhi; Zhang, Youlin; Lu, Xiaoxu

2013-03-01

The minimum Steiner tree problem has wide application background, such as transportation system, communication network, pipeline design and VISL, etc. It is unfortunately that the computational complexity of the problem is NP-hard. People are common to find some special problems to consider. In this paper, we first put forward a restricted Steiner tree problem, which the fixed vertices are in the same side of one line L and we find a vertex on L such the length of the tree is minimal. By the definition and the complexity of the Steiner tree problem, we know that the complexity of this problem is also Np-complete. In the part one, we have considered there are two fixed vertices to find the restricted Steiner tree problem. Naturally, we consider there are three fixed vertices to find the restricted Steiner tree problem. And we also use the geometric method to solve such the problem.

Dementia Research: Populations, Progress, Problems, and Predictions.

PubMed

Hunter, Sally; Smailagic, Nadja; Brayne, Carol

2018-05-16

Alzheimer's disease (AD) is a clinicopathologically defined syndrome leading to cognitive impairment. Following the recent failures of amyloid-based randomized controlled trials to change the course of AD, there are growing calls for a re-evaluation of basic AD research. Epidemiology offers one approach to integrating the available evidence. Here we examine relationships between evidence from population-based, clinicopathological studies of brain aging and a range of hypotheses from all areas of AD research. We identify various problems, including a lack of systematic approach to measurement of clinical and neuropathological factors associated with dementia in experimental and clinical settings, poor understanding of the strengths and weaknesses of different observational and experimental designs, a lack of clarity in relation to disease definitions from the clinical, neuropathological, and molecular perspectives, inadequate characterization of brain aging in the human population, difficulties in translation between laboratory-based and population-based evidence bases, and a lack of communication between different sections of the dementia research community. Population studies highlight complexity and predict that therapeutic approaches based on single disease features will not be successful. Better characterization of brain aging in the human population is urgently required to select biomarkers and therapeutic targets that are meaningful to human disease. The generation of detailed and reliable evidence must be addressed before progress toward therapeutic interventions can be made.

Contemporary Evaluation and Management of the Diabetic Foot

PubMed Central

Sumpio, Bauer E.

2012-01-01

Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field. PMID:24278695

Contemporary evaluation and management of the diabetic foot.

PubMed

Sumpio, Bauer E

2012-01-01

Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field.

From Paper to PDA: Design and Evaluation of a Clinical Ward Instruction on a Mobile Device

NASA Astrophysics Data System (ADS)

Kanstrup, Anne Marie; Stage, Jan

Mobile devices with small screens and minimal facilities for interaction are increasingly being used in complex human activities for accessing and processing information, while the user is moving. This paper presents a case study of the design and evaluation of a mobile system, which involved transformation of complex text and tables to digital format on a PDA. The application domain was an emergency medical ward, and the user group was junior registrars. We designed a PDA-based system for accessing information, focusing on the ward instruction, implemented a prototype and evaluated it for usability and utility. The evaluation results indicate significant problems in the interaction with the system as well as the extent to which the system is useful for junior registrars in their daily work.

Direct EIT reconstructions of complex admittivities on a chest-shaped domain in 2-D.

PubMed

Hamilton, Sarah J; Mueller, Jennifer L

2013-04-01

Electrical impedance tomography (EIT) is a medical imaging technique in which current is applied on electrodes on the surface of the body, the resulting voltage is measured, and an inverse problem is solved to recover the conductivity and/or permittivity in the interior. Images are then formed from the reconstructed conductivity and permittivity distributions. In the 2-D geometry, EIT is clinically useful for chest imaging. In this work, an implementation of a D-bar method for complex admittivities on a general 2-D domain is presented. In particular, reconstructions are computed on a chest-shaped domain for several realistic phantoms including a simulated pneumothorax, hyperinflation, and pleural effusion. The method demonstrates robustness in the presence of noise. Reconstructions from trigonometric and pairwise current injection patterns are included.

Factors of Problem-Solving Competency in a Virtual Chemistry Environment: The Role of Metacognitive Knowledge about Strategies

ERIC Educational Resources Information Center

Scherer, Ronny; Tiemann, Rudiger

2012-01-01

The ability to solve complex scientific problems is regarded as one of the key competencies in science education. Until now, research on problem solving focused on the relationship between analytical and complex problem solving, but rarely took into account the structure of problem-solving processes and metacognitive aspects. This paper,…

Determining the Effects of Cognitive Style, Problem Complexity, and Hypothesis Generation on the Problem Solving Ability of School-Based Agricultural Education Students

ERIC Educational Resources Information Center

Blackburn, J. Joey; Robinson, J. Shane

2016-01-01

The purpose of this experimental study was to assess the effects of cognitive style, problem complexity, and hypothesis generation on the problem solving ability of school-based agricultural education students. Problem solving ability was defined as time to solution. Kirton's Adaption-Innovation Inventory was employed to assess students' cognitive…

Multichromosomal median and halving problems under different genomic distances

PubMed Central

Tannier, Eric; Zheng, Chunfang; Sankoff, David

2009-01-01

Background Genome median and genome halving are combinatorial optimization problems that aim at reconstructing ancestral genomes as well as the evolutionary events leading from the ancestor to extant species. Exploring complexity issues is a first step towards devising efficient algorithms. The complexity of the median problem for unichromosomal genomes (permutations) has been settled for both the breakpoint distance and the reversal distance. Although the multichromosomal case has often been assumed to be a simple generalization of the unichromosomal case, it is also a relaxation so that complexity in this context does not follow from existing results, and is open for all distances. Results We settle here the complexity of several genome median and halving problems, including a surprising polynomial result for the breakpoint median and guided halving problems in genomes with circular and linear chromosomes, showing that the multichromosomal problem is actually easier than the unichromosomal problem. Still other variants of these problems are NP-complete, including the DCJ double distance problem, previously mentioned as an open question. We list the remaining open problems. Conclusion This theoretical study clears up a wide swathe of the algorithmical study of genome rearrangements with multiple multichromosomal genomes. PMID:19386099

Portrait of Candida Species Biofilm Regulatory Network Genes.

PubMed

Araújo, Daniela; Henriques, Mariana; Silva, Sónia

2017-01-01

Most cases of candidiasis have been attributed to Candida albicans, but Candida glabrata, Candida parapsilosis and Candida tropicalis, designated as non-C. albicans Candida (NCAC), have been identified as frequent human pathogens. Moreover, Candida biofilms are an escalating clinical problem associated with significant rates of mortality. Biofilms have distinct developmental phases, including adhesion/colonisation, maturation and dispersal, controlled by complex regulatory networks. This review discusses recent advances regarding Candida species biofilm regulatory network genes, which are key components for candidiasis. Copyright © 2016 Elsevier Ltd. All rights reserved.

Patient care information systems and physicians: the transition from technology icon to health care instrument.

PubMed

Bria, W F

1993-11-01

We have discussed several important transitions now occurring in PCIS that promise to improve the utility and availability of these systems for the average physician. Charles Babbage developed the first computers as "thinking machines" so that we may extend our ability to grapple with more and more complex problems. If current trends continue, we will finally witness the evolution of patient care computing from information icons of the few to clinical instruments improving the quality of medical decision making and care for all patients.

Assessing esophageal dysphagia.

PubMed

Kruger, Danielle

2014-05-01

Dysphagia, or difficulty swallowing, is a common problem. Although most cases are attributable to benign disease processes, dysphagia is also a key symptom in several malignancies, making it an important symptom to evaluate. The differential diagnosis of dysphagia requires an understanding of deglutition, in particular the oropharyngeal versus esophageal stages. Stroke is the leading cause of oropharyngeal dysphagia, which is common in older adults and frequently presents as part of a broader complex of clinical manifestations. In esophageal dysphagia, difficulty swallowing is often the main complaint and is caused by localized neuromuscular disorders or obstructive lesions.

Length of stay after vaginal birth: sociodemographic and readiness-for-discharge factors.

PubMed

Weiss, Marianne; Ryan, Polly; Lokken, Lisa; Nelson, Magdalen

2004-06-01

The impact of reductions in postpartum length of stay have been widely reported, but factors influencing length of hospital stay after vaginal birth have received less attention. The study purpose was to compare the sociodemographic characteristics and readiness for discharge of new mothers and their newborns at 3 discharge time intervals, and to determine which variables were associated with postpartum length of stay. The study sample comprised 1,192 mothers who were discharged within 2 postpartum days after uncomplicated vaginal birth at a tertiary perinatal center in the midwestern United States. The sample was divided into 3 postpartum length-of-stay groups: group 1 (18-30 hr), group 2 (31-42 hr), and group 3 (43-54 hr). Sociodemographic and readiness-for-discharge data were collected by self-report and from a computerized hospital information system. Measures of readiness for discharge included perceived readiness (single item and Readiness for Discharge After Birth Scale), documented maternal and neonatal clinical problems, and feeding method. Compared with other groups, the longest length-of-stay group was older; of higher socioeconomic status and education; and with more primiparous, breastfeeding, white, married mothers who were living with the baby's father, had adequate home help, and had a private payor source. This group also reported greater readiness for discharge, but their newborns had more documented clinical problems during the postbirth hospitalization. In logistic regression modeling, earlier discharge was associated with young age, multiparity, public payor source, low socioeconomic status, lack of readiness for discharge, bottle-feeding, and absence of a neonatal clinical problem. Sociodemographic characteristics and readiness for discharge (clinical and perceived) were associated with length of postpartum hospital stay. Length of stay is an outcome of a complex interface between patient, provider, and payor influences on discharge timing that requires additional study. Including perceived readiness for discharge in clinical discharge criteria will add an important dimension to assessment of readiness for discharge after birth.

Hunter disease eClinic: interactive, computer-assisted, problem-based approach to independent learning about a rare genetic disease.

PubMed

Al-Jasmi, Fatma; Moldovan, Laura; Clarke, Joe T R

2010-10-25

Computer-based teaching (CBT) is a well-known educational device, but it has never been applied systematically to the teaching of a complex, rare, genetic disease, such as Hunter disease (MPS II). To develop interactive teaching software functioning as a virtual clinic for the management of MPS II. The Hunter disease eClinic, a self-training, user-friendly educational software program, available at the Lysosomal Storage Research Group (http://www.lysosomalstorageresearch.ca), was developed using the Adobe Flash multimedia platform. It was designed to function both to provide a realistic, interactive virtual clinic and instantaneous access to supporting literature on Hunter disease. The Hunter disease eClinic consists of an eBook and an eClinic. The eClinic is the interactive virtual clinic component of the software. Within an environment resembling a real clinic, the trainee is instructed to perform a medical history, to examine the patient, and to order appropriate investigation. The program provides clinical data derived from the management of actual patients with Hunter disease. The eBook provides instantaneous, electronic access to a vast collection of reference information to provide detailed background clinical and basic science, including relevant biochemistry, physiology, and genetics. In the eClinic, the trainee is presented with quizzes designed to provide immediate feedback on both trainee effectiveness and efficiency. User feedback on the merits of the program was collected at several seminars and formal clinical rounds at several medical centres, primarily in Canada. In addition, online usage statistics were documented for a 2-year period. Feedback was consistently positive and confirmed the practical benefit of the program. The online English-language version is accessed daily by users from all over the world; a Japanese translation of the program is also available. The Hunter disease eClinic employs a CBT model providing the trainee with realistic clinical problems, coupled with comprehensive basic and clinical reference information by instantaneous access to an electronic textbook, the eBook. The program was rated highly by attendees at national and international presentations. It provides a potential model for use as an educational approach to other rare genetic diseases.

Program development and defining characteristics of returning military in a VA Polytrauma Network Site.

PubMed

Lew, Henry L; Poole, John H; Vanderploeg, Rodney D; Goodrich, Gregory L; Dekelboum, Sharon; Guillory, Sylvia B; Sigford, Barbara; Cifu, David X

2007-01-01

The conflicts in Iraq and Afghanistan have resulted in a new generation of combat survivors with complex physical injuries and emotional trauma. This article reports the initial implementation of the Polytrauma Network Site (PNS) clinic, which is a key component of the Department of Veterans Affairs (VA) Polytrauma System of Care and serves military personnel returning from combat. The PNS clinic in Palo Alto, California, is described to demonstrate the VA healthcare system's evolving effort to meet the clinical needs of this population. We summarize the following features of this interdisciplinary program: (1) sequential assessment, from initial traumatic brain injury screening throughout our catchment area to evaluation by the PNS clinic team, and (2) clinical evaluation results for the first 62 clinic patients. In summary, this population shows a high prevalence of postconcussion symptoms, posttraumatic stress, poor cognitive performance, head and back pain, auditory and visual symptoms, and problems with dizziness or balance. An anonymous patient feedback survey, which we used to fine-tune the clinic process, reflected high satisfaction with this new program. We hope that the lessons learned at one site will enhance the identification and treatment of veterans with polytrauma across the country.

Complexity of GPs' explanations about mental health problems: development, reliability, and validity of a measure

PubMed Central

Cape, John; Morris, Elena; Burd, Mary; Buszewicz, Marta

2008-01-01

Background How GPs understand mental health problems determines their treatment choices; however, measures describing GPs' thinking about such problems are not currently available. Aim To develop a measure of the complexity of GP explanations of common mental health problems and to pilot its reliability and validity. Design of study A qualitative development of the measure, followed by inter-rater reliability and validation pilot studies. Setting General practices in North London. Method Vignettes of simulated consultations with patients with mental health problems were videotaped, and an anchored measure of complexity of psychosocial explanation in response to these vignettes was developed. Six GPs, four psychologists, and two lay people viewed the vignettes. Their responses were rated for complexity, both using the anchored measure and independently by two experts in primary care mental health. In a second reliability and revalidation study, responses of 50 GPs to two vignettes were rated for complexity. The GPs also completed a questionnaire to determine their interest and training in mental health, and they completed the Depression Attitudes Questionnaire. Results Inter-rater reliability of the measure of complexity of explanation in both pilot studies was satisfactory (intraclass correlation coefficient = 0.78 and 0.72). The measure correlated with expert opinion as to what constitutes a complex explanation, and the responses of psychologists, GPs, and lay people differed in measured complexity. GPs with higher complexity scores had greater interest, more training in mental health, and more positive attitudes to depression. Conclusion Results suggest that the complexity of GPs' psychosocial explanations about common mental health problems can be reliably and validly assessed by this new standardised measure. PMID:18505616

Predicting Development of Mathematical Word Problem Solving Across the Intermediate Grades

PubMed Central

Tolar, Tammy D.; Fuchs, Lynn; Cirino, Paul T.; Fuchs, Douglas; Hamlett, Carol L.; Fletcher, Jack M.

2012-01-01

This study addressed predictors of the development of word problem solving (WPS) across the intermediate grades. At beginning of 3rd grade, 4 cohorts of students (N = 261) were measured on computation, language, nonverbal reasoning skills, and attentive behavior and were assessed 4 times from beginning of 3rd through end of 5th grade on 2 measures of WPS at low and high levels of complexity. Language skills were related to initial performance at both levels of complexity and did not predict growth at either level. Computational skills had an effect on initial performance in low- but not high-complexity problems and did not predict growth at either level of complexity. Attentive behavior did not predict initial performance but did predict growth in low-complexity, whereas it predicted initial performance but not growth for high-complexity problems. Nonverbal reasoning predicted initial performance and growth for low-complexity WPS, but only growth for high-complexity WPS. This evidence suggests that although mathematical structure is fixed, different cognitive resources may act as limiting factors in WPS development when the WPS context is varied. PMID:23325985

Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records.

PubMed

Luo, Yuan; Szolovits, Peter

2016-01-01

In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen's interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen's relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions.

Efficient Queries of Stand-off Annotations for Natural Language Processing on Electronic Medical Records

PubMed Central

Luo, Yuan; Szolovits, Peter

2016-01-01

In natural language processing, stand-off annotation uses the starting and ending positions of an annotation to anchor it to the text and stores the annotation content separately from the text. We address the fundamental problem of efficiently storing stand-off annotations when applying natural language processing on narrative clinical notes in electronic medical records (EMRs) and efficiently retrieving such annotations that satisfy position constraints. Efficient storage and retrieval of stand-off annotations can facilitate tasks such as mapping unstructured text to electronic medical record ontologies. We first formulate this problem into the interval query problem, for which optimal query/update time is in general logarithm. We next perform a tight time complexity analysis on the basic interval tree query algorithm and show its nonoptimality when being applied to a collection of 13 query types from Allen’s interval algebra. We then study two closely related state-of-the-art interval query algorithms, proposed query reformulations, and augmentations to the second algorithm. Our proposed algorithm achieves logarithmic time stabbing-max query time complexity and solves the stabbing-interval query tasks on all of Allen’s relations in logarithmic time, attaining the theoretic lower bound. Updating time is kept logarithmic and the space requirement is kept linear at the same time. We also discuss interval management in external memory models and higher dimensions. PMID:27478379

Gastric volvulus in children--a diagnostic problem: two case reports.

PubMed

Trecroci, Ilaria; Morabito, Giuliana; Romano, Claudio; Salamone, Ignazio

2016-05-31

Gastric volvulus is a clinically significant cause of acute or recurrent abdominal pain and chronic vomiting in children. Since related clinical symptoms are nonspecific, clinicians often refer to radiologists for a diagnostic evaluation. Early diagnosis is crucial to prevent life-threatening complications of prolonged volvulus, such as intestinal ischemia, infarction, strangulation, necrosis, and perforation that may require immediate surgical treatment. In this report, we describe clinical and radiological criteria for diagnosis of gastric volvulus in children. We describe two pediatric clinical cases. A 16-month-old female Caucasian child was admitted to our hospital for recurrent postprandial vomiting episodes, which started at 11 months old, associated with failure to thrive. A 9-month-old term-born baby boy was admitted for chronic, recurrent, postprandial vomiting, which started at 7 months of age, with progressive failure to thrive. A barium study allowed definitive diagnosis of chronic organoaxial gastric volvulus. Gastric volvulus is an extremely rare disorder in the pediatric population. It can be considered a complex clinical condition with regard to the etiology and the management. A nonoperative approach is advisable in the absence of warning signs.

[Perinatal Information System. Incorporation latency and impact on perinatal clinical registry].

PubMed

Simini, F; Fernández, A; Sosa, C; Díaz Rossello, J L

2001-10-01

The Perinatal Information System (SIP) is a clinical record, local management and quality assurance software standard in Latin America and the Caribbean. The time to implement SIP in a Maternity Hospital is evaluated as well as the effect of statistics on perinatal health indicators in subsequent years. In the sample of 20 Maternity Hospitals (5 Countries, 40% Private and 60% Public) 85% had a reliable information system by the third year of use of SIP. 15% of hospitals still had problems at that time that were already clear during the second year, a time corrective measures can still be taken. The evaluation of the impact of yearly reports shows that 58% of recommendations were fulfilled, specially those regarding the complete filling-in of clinical records (62%) and to a lesser extent variables that reflect clinical practices and organization of services (52%). The conclusion is that Maternity Hospitals in Latin America and the Caribbean have the capacity to adopt a complex tool of computerized clinical records for quality assurance of perinatal care and monitoring of health indicators.

Complex facial deformity reconstruction with a surgical guide incorporating a built-in occlusal stent as the positioning reference.

PubMed

Fang, Jing-Jing; Liu, Jia-Kuang; Wu, Tzu-Chieh; Lee, Jing-Wei; Kuo, Tai-Hong

2013-05-01

Computer-aided design has gained increasing popularity in clinical practice, and the advent of rapid prototyping technology has further enhanced the quality and predictability of surgical outcomes. It provides target guides for complex bony reconstruction during surgery. Therefore, surgeons can efficiently and precisely target fracture restorations. Based on three-dimensional models generated from a computed tomographic scan, precise preoperative planning simulation on a computer is possible. Combining the interdisciplinary knowledge of surgeons and engineers, this study proposes a novel surgical guidance method that incorporates a built-in occlusal wafer that serves as the positioning reference.Two patients with complex facial deformity suffering from severe facial asymmetry problems were recruited. In vitro facial reconstruction was first rehearsed on physical models, where a customized surgical guide incorporating a built-in occlusal stent as the positioning reference was designed to implement the surgery plan. This study is intended to present the authors' preliminary experience in a complex facial reconstruction procedure. It suggests that in regions with less information, where intraoperative computed tomographic scans or navigation systems are not available, our approach could be an effective, expedient, straightforward aid to enhance surgical outcome in a complex facial repair.

Complex Problem Solving in a Workplace Setting.

ERIC Educational Resources Information Center

Middleton, Howard

2002-01-01

Studied complex problem solving in the hospitality industry through interviews with six office staff members and managers. Findings show it is possible to construct a taxonomy of problem types and that the most common approach can be termed "trial and error." (SLD)

Preadoption adversity and long-term clinical-range behavior problems in adopted Chinese girls.

PubMed

Tan, Tony Xing; Camras, Linda A; Kim, Eun Sook

2016-04-01

In this study, we report findings on the role of preadoption adversity on long-term clinical-range problems in adopted Chinese girls. Four waves (2005, 2007, 2009 and 2011) of problem behavior data on 1,223 adopted Chinese girls (M = 4.86 years, SD = 2.82 in 2005) were collected from the adoptive mothers with the Child Behavior Checklist (CBCL). At Wave 1 (2005), data on the following indicators of preadoption adversity was collected: age at adoption, physical signs/symptoms (e.g., sores) of preadoption adversity, developmental delays at arrival, refusal/avoidance behaviors and crying/clinging behaviors toward adoptive parents during the first 3 weeks of adoption. We found that the percentage of clinical-range internalizing problems was 11.1%, 16.5%, 11.3%, and 16.1% at Wave 1, Wave 2, Wave 3, and Wave 4, respectively; the corresponding percentage of clinical-range externalizing problems was 8.4%, 10.5%, 8.4% and 9.9% respectively; and the corresponding percentage of clinical-range total CBCL problems was 9.3%, 13.0%, 9.8% and 12.6% respectively. Analyses with Mplus showed that controlling for demographic variables, indicators of preadoption adversity, except age at adoption, increased the odds for clinical-range behavior problems. Longitudinal path models revealed that controlling for demographic variables and the children's adjustment status in the previous wave, refusal/avoidance remained significant in predicting clinical-range internalizing, externalizing and total CBCL problems at Wave 2, delays at arrival and signs/symptoms were significant in predicting clinical-range internalizing problems at Wave 3. Overall, adoptees with clinical-range CBCL problems in earlier waves were 9-28 times as likely to show clinical-range CBCL problems in subsequent waves. (c) 2016 APA, all rights reserved).

Insight and analysis problem solving in microbes to machines.

PubMed

Clark, Kevin B

2015-11-01

A key feature for obtaining solutions to difficult problems, insight is oftentimes vaguely regarded as a special discontinuous intellectual process and/or a cognitive restructuring of problem representation or goal approach. However, this nearly century-old state of art devised by the Gestalt tradition to explain the non-analytical or non-trial-and-error, goal-seeking aptitude of primate mentality tends to neglect problem-solving capabilities of lower animal phyla, Kingdoms other than Animalia, and advancing smart computational technologies built from biological, artificial, and composite media. Attempting to provide an inclusive, precise definition of insight, two major criteria of insight, discontinuous processing and problem restructuring, are here reframed using terminology and statistical mechanical properties of computational complexity classes. Discontinuous processing becomes abrupt state transitions in algorithmic/heuristic outcomes or in types of algorithms/heuristics executed by agents using classical and/or quantum computational models. And problem restructuring becomes combinatorial reorganization of resources, problem-type substitution, and/or exchange of computational models. With insight bounded by computational complexity, humans, ciliated protozoa, and complex technological networks, for example, show insight when restructuring time requirements, combinatorial complexity, and problem type to solve polynomial and nondeterministic polynomial decision problems. Similar effects are expected from other problem types, supporting the idea that insight might be an epiphenomenon of analytical problem solving and consequently a larger information processing framework. Thus, this computational complexity definition of insight improves the power, external and internal validity, and reliability of operational parameters with which to classify, investigate, and produce the phenomenon for computational agents ranging from microbes to man-made devices. Copyright © 2015 Elsevier Ltd. All rights reserved.

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

PubMed Central

Musgrove, John L.; Morris, Jason; Estrada, Carlos A.; Kraemer, Ryan R.

2016-01-01

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms. PMID:27168884

Clinical Reasoning Terms Included in Clinical Problem Solving Exercises?

PubMed

Musgrove, John L; Morris, Jason; Estrada, Carlos A; Kraemer, Ryan R

2016-05-01

Background Published clinical problem solving exercises have emerged as a common tool to illustrate aspects of the clinical reasoning process. The specific clinical reasoning terms mentioned in such exercises is unknown. Objective We identified which clinical reasoning terms are mentioned in published clinical problem solving exercises and compared them to clinical reasoning terms given high priority by clinician educators. Methods A convenience sample of clinician educators prioritized a list of clinical reasoning terms (whether to include, weight percentage of top 20 terms). The authors then electronically searched the terms in the text of published reports of 4 internal medicine journals between January 2010 and May 2013. Results The top 5 clinical reasoning terms ranked by educators were dual-process thinking (weight percentage = 24%), problem representation (12%), illness scripts (9%), hypothesis generation (7%), and problem categorization (7%). The top clinical reasoning terms mentioned in the text of 79 published reports were context specificity (n = 20, 25%), bias (n = 13, 17%), dual-process thinking (n = 11, 14%), illness scripts (n = 11, 14%), and problem representation (n = 10, 13%). Context specificity and bias were not ranked highly by educators. Conclusions Some core concepts of modern clinical reasoning theory ranked highly by educators are mentioned explicitly in published clinical problem solving exercises. However, some highly ranked terms were not used, and some terms used were not ranked by the clinician educators. Effort to teach clinical reasoning to trainees may benefit from a common nomenclature of clinical reasoning terms.

Bioavailability and activity of phytosome complexes from botanical polyphenols: the silymarin, curcumin, green tea, and grape seed extracts.

PubMed

Kidd, Parris M

2009-09-01

Plant-derived polyphenols are increasingly receiving attention as dietary supplements for the homeostatic management of inflammation, to support detoxication, and for anticancer, weight loss, and other benefits. Their pro-homeostatic effects on genes, transcription factors, enzymes, and cell signaling pathways are being intensively explored, but the poor bioavailability of some polyphenols likely contributes to poor clinical trial outcomes. This review covers four polyphenol preparations with poor bioavailability and their complexation into phytosomes to bypass this problem. Silybin and the other silymarin flavonolignans from milk thistle conserve tissue glutathione, are liver-protective, and have anticancer potential. Curcumin and its related diphenolic curcuminoids have potent antioxidant, anti-inflammatory, and anti-carcinogenic properties. The green tea flavan-3-ol catechins have antioxidant, anti-inflammatory, cardio- and neuro-protective effects, and anti-carcinogenic benefits, with fat oxidation effects coupled to weight loss. The complex grape seed proanthocyanidin mix (including catechin and epicatechin monomers and oligomers) counters oxidative stress and protects the circulatory system. For each of these preparations, conversion into phytosomes has improved efficacy without compromising safety. The phytosome technology creates intermolecular bonding between individual polyphenol molecules and one or more molecules of the phospholipid, phosphatidylcholine (PC). Molecular imaging suggests that PC molecule(s) enwrap each polyphenol; upon oral intake the amphipathic PC molecules likely usher the polyphenol through the intestinal epithelial cell outer membrane, subsequently accessing the bloodstream. PC itself has proven clinical efficacy that contributes to phytosome in vivo actions. As a molecular delivery vehicle, phytosome technology substantially improves the clinical applicabilities of polyphenols and other poorly absorbed plant medicinals.

Symptoms and Needs of Head and Neck Cancer Patients at Diagnosis of Incurability - Prevalences, Clinical Implications, and Feasibility of a Prospective Longitudinal Multicenter Cohort Study.

PubMed

Alt-Epping, Bernd; Seidel, Wiebke; Vogt, Jeannette; Mehnert, Anja; Thomas, Michael; van Oorschot, Birgitt; Wolff, Hendrik; Schliephake, Henning; Canis, Martin; Dröge, Leif H; Nauck, Friedemann; Lordick, Florian

2016-01-01

Little is known about the physical symptoms and psychosocial burden of patients at the time of diagnosis of an incurable situation, although cancer treatment guidelines demand early assessment and integration of palliative care concepts, beginning from the diagnosis of incurability. Therefore, we initiated a prospective longitudinal multicenter cohort study assessing the symptoms and needs of patients suffering from incurable cancer (various entities), from the time of diagnosing incurability (i.e., before palliative anticancer treatment was initiated) and in 3-monthly intervals thereafter, by using validated self-reporting tools. Here, we focus on patients with head and neck cancer and present preliminary results on symptoms and need prevalences, on clinical implications, and on the feasibility of a methodologically complex assessment procedure in a particularly vulnerable study population. 22 patients completed the first visit. The Eastern Cooperative Oncology Group (ECOG) performance scores and most physical symptoms and psychosocial items varied between the extremes, from a virtually uncompromised condition to extremely perceived symptoms and needs. If intense face-to-face study support was provided, the study concept proved to be feasible, despite the complexity of assessment, problems in interdisciplinary and patient communication, comorbidities, and early death from complications. The striking variability in the perceived symptom and need intensities requires a highly individualized approach. For clinical purposes, a less complex screening procedure would be desirable, in order to enable a routine, early and comprehensive support, including palliative care services. © 2016 S. Karger GmbH, Freiburg.

Radiological clinical trials: Proposal of a problem-finding questionnaire to improve study success.

PubMed

Valdora, Francesca; Bignotti, Bianca; Calabrese, Massimo; Houssami, Nehmat; Tagliafico, Alberto

2016-12-26

To develop a survey to help define the main problems in radiological clinical trials. Since 2006, we have managed seven different radiological clinical trials recruiting patients in academic and non-academic centres. We developed a preliminary questionnaire using a four-round Delphi approach to identify problems occurring in radiological clinical trials run at our centre. We investigated the recruitment experience, involvement of all multi-disciplinary team members and main obstacles to completing the projects. A final round of Delphi processes elucidated solutions to the identified problems. Among 19/20 (95%) respondents, 10 (53%) were young physicians (under 35 years old), and the respondents included non-faculty members, fellows, residents, and undergraduate students. Ninety-four percent (18/19) of respondents showed interest in conducting clinical trials. On a scale of 1 to 10, the problems with higher/worse scores (8-9) were related to technical or communication problems. The most frequent problems across all studies were technical problems related to clinical trial equipment, insufficient willingness to participate, obstacles to understanding the design of electronic-case report form and extra work. The developed questionnaire identified the main recurring problems in radiological clinical trials as perceived by end-users and helped define possible solutions that are mostly related to having dedicated clinical trial research staff.

Heuristics in Managing Complex Clinical Decision Tasks in Experts’ Decision Making

PubMed Central

Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

2016-01-01

Background Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. Objective The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. Method After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. Results We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Conclusion Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Application Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design. PMID:27275019

Heuristics in Managing Complex Clinical Decision Tasks in Experts' Decision Making.

PubMed

Islam, Roosan; Weir, Charlene; Del Fiol, Guilherme

2014-09-01

Clinical decision support is a tool to help experts make optimal and efficient decisions. However, little is known about the high level of abstractions in the thinking process for the experts. The objective of the study is to understand how clinicians manage complexity while dealing with complex clinical decision tasks. After approval from the Institutional Review Board (IRB), three clinical experts were interviewed the transcripts from these interviews were analyzed. We found five broad categories of strategies by experts for managing complex clinical decision tasks: decision conflict, mental projection, decision trade-offs, managing uncertainty and generating rule of thumb. Complexity is created by decision conflicts, mental projection, limited options and treatment uncertainty. Experts cope with complexity in a variety of ways, including using efficient and fast decision strategies to simplify complex decision tasks, mentally simulating outcomes and focusing on only the most relevant information. Understanding complex decision making processes can help design allocation based on the complexity of task for clinical decision support design.

Translating concepts of complexity to the field of ergonomics.

PubMed

Walker, Guy H; Stanton, Neville A; Salmon, Paul M; Jenkins, Daniel P; Rafferty, Laura

2010-10-01

Since 1958 more than 80 journal papers from the mainstream ergonomics literature have used either the words 'complex' or 'complexity' in their titles. Of those, more than 90% have been published in only the past 20 years. This observation communicates something interesting about the way in which contemporary ergonomics problems are being understood. The study of complexity itself derives from non-linear mathematics but many of its core concepts have found analogies in numerous non-mathematical domains. Set against this cross-disciplinary background, the current paper aims to provide a similar initial mapping to the field of ergonomics. In it, the ergonomics problem space, complexity metrics and powerful concepts such as emergence raise complexity to the status of an important contingency factor in achieving a match between ergonomics problems and ergonomics methods. The concept of relative predictive efficiency is used to illustrate how this match could be achieved in practice. What is clear overall is that a major source of, and solution to, complexity are the humans in systems. Understanding complexity on its own terms offers the potential to leverage disproportionate effects from ergonomics interventions and to tighten up the often loose usage of the term in the titles of ergonomics papers. STATEMENT OF RELEVANCE: This paper reviews and discusses concepts from the study of complexity and maps them to ergonomics problems and methods. It concludes that humans are a major source of and solution to complexity in systems and that complexity is a powerful contingency factor, which should be considered to ensure that ergonomics approaches match the true nature of ergonomics problems.

Entropy-based consensus clustering for patient stratification.

PubMed

Liu, Hongfu; Zhao, Rui; Fang, Hongsheng; Cheng, Feixiong; Fu, Yun; Liu, Yang-Yu

2017-09-01

Patient stratification or disease subtyping is crucial for precision medicine and personalized treatment of complex diseases. The increasing availability of high-throughput molecular data provides a great opportunity for patient stratification. Many clustering methods have been employed to tackle this problem in a purely data-driven manner. Yet, existing methods leveraging high-throughput molecular data often suffers from various limitations, e.g. noise, data heterogeneity, high dimensionality or poor interpretability. Here we introduced an Entropy-based Consensus Clustering (ECC) method that overcomes those limitations all together. Our ECC method employs an entropy-based utility function to fuse many basic partitions to a consensus one that agrees with the basic ones as much as possible. Maximizing the utility function in ECC has a much more meaningful interpretation than any other consensus clustering methods. Moreover, we exactly map the complex utility maximization problem to the classic K -means clustering problem, which can then be efficiently solved with linear time and space complexity. Our ECC method can also naturally integrate multiple molecular data types measured from the same set of subjects, and easily handle missing values without any imputation. We applied ECC to 110 synthetic and 48 real datasets, including 35 cancer gene expression benchmark datasets and 13 cancer types with four molecular data types from The Cancer Genome Atlas. We found that ECC shows superior performance against existing clustering methods. Our results clearly demonstrate the power of ECC in clinically relevant patient stratification. The Matlab package is available at http://scholar.harvard.edu/yyl/ecc . yunfu@ece.neu.edu or yyl@channing.harvard.edu. Supplementary data are available at Bioinformatics online. © The Author (2017). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Bipolar disorder-methodological problems and future perspectives

PubMed Central

Angst, Jules

2008-01-01

Since its “rebirth” in 1966, bipolar disorder (BPD) has rapidly come to occupy a central position in the research and treatment of mood disorders. Compared with major depressive disorder (MDD), BPD is a more serious condition, characterized by much more frequent recurrence, more complex comorbidity, and higher mortality. One major problem is the lack of valid definitions in adult and in child psychiatry; the current definitions are unsatisfactory, and heavily favor an overdiagnosis of MDD. Biological research is partially based on those definitions, which have a short half-life. An additional, dimensional, approach, quantifying hypomania, depression, and anxiety by self-assessment and symptom checklists is recommended, A further, related problem is the early recognition of the onset of BPD, especially in adolescence, and the identification of correlates in childhood. Early and timely diagnosis of BPD is necessary to enable prompt intervention and secondary prevention of the disorder. The paper describes the current status and future directions of developing clinical concepts of bipolarity PMID:18689284

Micro-CT image reconstruction based on alternating direction augmented Lagrangian method and total variation.

PubMed

Gopi, Varun P; Palanisamy, P; Wahid, Khan A; Babyn, Paul; Cooper, David

2013-01-01

Micro-computed tomography (micro-CT) plays an important role in pre-clinical imaging. The radiation from micro-CT can result in excess radiation exposure to the specimen under test, hence the reduction of radiation from micro-CT is essential. The proposed research focused on analyzing and testing an alternating direction augmented Lagrangian (ADAL) algorithm to recover images from random projections using total variation (TV) regularization. The use of TV regularization in compressed sensing problems makes the recovered image quality sharper by preserving the edges or boundaries more accurately. In this work TV regularization problem is addressed by ADAL which is a variant of the classic augmented Lagrangian method for structured optimization. The per-iteration computational complexity of the algorithm is two fast Fourier transforms, two matrix vector multiplications and a linear time shrinkage operation. Comparison of experimental results indicate that the proposed algorithm is stable, efficient and competitive with the existing algorithms for solving TV regularization problems. Copyright © 2013 Elsevier Ltd. All rights reserved.

An ethics dilemma: when parents and doctors disagree on the best treatment for the child.

PubMed

Oppenheim, Daniel; Brugières, Laurence; Corradini, Nadège; Vivant, Florence; Hartmann, Olivier

2004-09-01

The increasing complexity of present day medicine--with highly effective and yet risky treatments, individual and collective expectations, and evolving ideological and cultural landmarks--often gives rise to difficult ethical problems. Specific meetings are valuable for understanding such problems, acquiring the relevant skills and for gaining and transmitting experience on how to solve them. Parents and doctors may disagree about what is the best treatment. Such a difference of opinion is not rare but usually a solution can easily be found. This is not the case when the child is treated for a severe illness and when there is no clearly defined or satisfactory treatment for him\\her. We present how a dramatic conflict arose between the parents and the doctors faced with such a case (mostly because the staff failed to understand early enough the psychological factors at the root of the father's demands), how clinical, institutional and ethical problems were analysed during a meeting, and how they were solved.

Mental health problems in people living with HIV: changes in the last two decades: the London experience 1990–2014

PubMed Central

Adams, Catherine; Zacharia, Shilpa; Masters, Lisa; Coffey, Caroline; Catalan, Pepe

2016-01-01

ABSTRACT Mental health problems continue to be a significant comorbidity for people with HIV infection, even in the era of effective antiretroviral therapy. Here, we report on the changes in the mental health diagnoses based on clinical case reports amongst people with HIV referred to a specialist psychological medicine department over a 24-year period, which include the relative increase in depressive and anxiety disorders, often of a chronic nature, together with a decline in acute mental health syndromes, mania, and organic brain disorders. In addition, new challenges, like the presence of HIV and Hepatitis C co-infection, and the new problems created by recreational drugs, confirm the need for mental health services to be closely involved with the general medical services. A substantial proportion of people with HIV referred to specialist services suffer complex difficulties, which often require the collaboration of both psychiatrists and psychologists to deal effectively with their difficulties. PMID:26888472

An independent randomized clinical trial of multisystemic therapy with non-court-referred adolescents with serious conduct problems.

PubMed

Weiss, Bahr; Han, Susan; Harris, Vicki; Catron, Thomas; Ngo, Victoria K; Caron, Annalise; Gallop, Robert; Guth, Carol

2013-12-01

Adolescent conduct problems exact serious social as well as personal costs, and effective treatments are essential. One of the most widely disseminated and effective programs for the treatment of serious conduct problems in adolescents is Multisystemic Therapy (MST). However, most evaluations of MST have involved the developers of MST. The purpose of the present study was to conduct an independent evaluation of MST, with non-court-referred adolescents with conduct problems. Participants were 164 adolescents ages 11-18 years who were recruited from self-contained behavior intervention classrooms in public schools. Adolescents and their families were randomly assigned to receive MST or services as usual. Outcome measures assessed conduct problems, school functioning, and court records of criminal behavior. Participants were followed for 18 months after baseline using parent, adolescent, and teacher reports; arrest data were collected for 2.5 years postbaseline. Two of 4 primary outcome measures focused on externalizing problems showed significant treatment effects favoring MST. Several secondary and intervention targets pertaining to family functioning and parent psychopathology showed positive effects of MST, and no negative effects were identified. Results provide some further support for the effectiveness of MST, although smaller effect sizes than previous studies also suggest the complexity of successful dissemination, particularly to non-court-referred populations.

[Evaluation and treatment of sleep problems in children diagnosed with attention deficit hyperactivity disorder: an update of the evidence].

PubMed

Chamorro, M; Lara, J P; Insa, I; Espadas, M; Alda-Diez, J A

2017-05-01

Attention deficit hyperactivity disorder (ADHD) affects approximately 5% of all children and adolescents, and these patients frequently suffer from sleep problems. The association between sleep disorders and ADHD, however, is multifaceted and complex. To explore the relationship between sleep disorders and ADHD. Sleep problems in children with ADHD include altered sleep and specific disorders per se or that may be due to comorbid psychiatric disorders or to the stimulants they receive as treatment for their ADHD. Today, an evaluation of the sleep conditions in children with ADHD is recommended before starting pharmacological treatment. The first step in managing their sleep problems is good sleep hygiene and cognitive-behavioural psychotherapy. Another option is to consider modifying the dosage and formulation of the stimulants. Atomoxetine and melatonin are therapeutic alternatives for children with ADHD and more severe sleep problems. Specific treatments exist for respiratory and movement disorders during sleep. It is important to evaluate sleep in children who present symptoms suggestive of ADHD, since problems during sleep can play a causal role or exacerbate the clinical features of ADHD. Correct evaluation and treatment of sleep disorders increase the family's and the child's quality of life and can lessen the severity of the symptoms of ADHD.

Physician styles of decision-making for a complex condition: Type 2 diabetes with co-morbid mental illness.

PubMed

Trachtenberg, Felicia L; Pober, David M; Welch, Lisa C; McKinlay, John B

Variation in physician decisions may reflect personal styles of decision-making, as opposed to singular clinical actions and these styles may be applied differently depending on patient complexity. The objective of this study is to examine clusters of physician decision-making for type 2 diabetes, overall and in the presence of a mental health co-morbidity. This randomized balanced factorial experiment presented video vignettes of a "patient" with diagnosed, but uncontrolled type 2 diabetes. "Patients" were systematically varied by age, sex, race and co-morbidity (depression, schizophrenia with normal or bizarre affect, eczema as control). Two hundred and fifty-six primary care physicians, balanced by gender and experience level, completed a structured interview about clinical management. Cluster analysis identified 3 styles of diabetes management. "Minimalists" (n=84) performed fewer exams or tests compared to "middle of the road" physicians (n=84). "Interventionists" (n=88) suggested more medications and referrals. A second cluster analysis, without control for co-morbidities, identified an additional cluster of "information seekers" (n=15) who requested more additional information and referrals. Physicians ranking schizophrenia higher than diabetes on their problem list were more likely "minimalists" and none were "interventionists" or "information seekers". Variations in clinical management encompass multiple clinical actions and physicians subtly shift these decision-making styles depending on patient co-morbidities. Physicians' practice styles may help explain persistent differences in patient care. Training and continuing education efforts to encourage physicians to implement evidence-based clinical practice should account for general styles of decision-making and for how physicians process complicating comorbidities.

An Ensemble Framework Coping with Instability in the Gene Selection Process.

PubMed

Castellanos-Garzón, José A; Ramos, Juan; López-Sánchez, Daniel; de Paz, Juan F; Corchado, Juan M

2018-03-01

This paper proposes an ensemble framework for gene selection, which is aimed at addressing instability problems presented in the gene filtering task. The complex process of gene selection from gene expression data faces different instability problems from the informative gene subsets found by different filter methods. This makes the identification of significant genes by the experts difficult. The instability of results can come from filter methods, gene classifier methods, different datasets of the same disease and multiple valid groups of biomarkers. Even though there is a wide number of proposals, the complexity imposed by this problem remains a challenge today. This work proposes a framework involving five stages of gene filtering to discover biomarkers for diagnosis and classification tasks. This framework performs a process of stable feature selection, facing the problems above and, thus, providing a more suitable and reliable solution for clinical and research purposes. Our proposal involves a process of multistage gene filtering, in which several ensemble strategies for gene selection were added in such a way that different classifiers simultaneously assess gene subsets to face instability. Firstly, we apply an ensemble of recent gene selection methods to obtain diversity in the genes found (stability according to filter methods). Next, we apply an ensemble of known classifiers to filter genes relevant to all classifiers at a time (stability according to classification methods). The achieved results were evaluated in two different datasets of the same disease (pancreatic ductal adenocarcinoma), in search of stability according to the disease, for which promising results were achieved.

Tourette Syndrome and Chronic Tic Disorders: The Clinical Spectrum Beyond Tics.

PubMed

Martino, Davide; Ganos, Christos; Pringsheim, Tamara M

2017-01-01

The clinical surveillance and active management of Tourette syndrome (TS) and other primary chronic tic disorders cannot be limited to tics, as these patients manifest a spectrum of sensory-, behavioral-, cognitive-, and sleep-related problems that have a major impact on their functioning and quality of life, influencing enormously clinical decision making on a routine basis. The sensory phenomena of primary tic disorders consist of premonitory urges and heightened sensitivity to external somatosensory and interoceptive stimuli. Recent evidence suggests that raised interoceptive awareness may be related to the classical premonitory urges associated with tics. The burden of behavioral comorbidities is very important in determining the degree of disability of patients with primary tic disorders. Only 10%-15% of these patients presents exclusively with a tic disorder. Obsessive-compulsive disorder (OCD) are common in TS, and the clinical distinction between compulsions and complex tics may be difficult in some cases. "Tic-related OCD" represents a phenomenologically characteristic subtype of OCD, also associated with "just right" phenomena. Probably the presence of comorbid attention deficit/hyperactivity disorder is the main determinant of cognitive dysfunction in TS patients and influences heavily also the risk of developing disruptive behaviors. Mood and anxiety disorders, impulse control disorders, rage attacks, "impulsive" tic-like behaviors (e.g., nonobscene socially inappropriate behaviors, and self-injurious behaviors), and autism spectrum disorders complete the wide psychopathological spectrum of primary chronic tic disorders. Moreover, specific sleep abnormalities have been reported in TS patients, although more research is needed on this specific clinical problem. As in other areas of clinical neuroscience, a comprehensive approach to both motor and nonmotor aspects of this group of disorders will help personalizing treatment interventions and, ultimately, improve quality of care. © 2017 Elsevier Inc. All rights reserved.

A semiparametric Bayesian proportional hazards model for interval censored data with frailty effects.

PubMed

Henschel, Volkmar; Engel, Jutta; Hölzel, Dieter; Mansmann, Ulrich

2009-02-10

Multivariate analysis of interval censored event data based on classical likelihood methods is notoriously cumbersome. Likelihood inference for models which additionally include random effects are not available at all. Developed algorithms bear problems for practical users like: matrix inversion, slow convergence, no assessment of statistical uncertainty. MCMC procedures combined with imputation are used to implement hierarchical models for interval censored data within a Bayesian framework. Two examples from clinical practice demonstrate the handling of clustered interval censored event times as well as multilayer random effects for inter-institutional quality assessment. The software developed is called survBayes and is freely available at CRAN. The proposed software supports the solution of complex analyses in many fields of clinical epidemiology as well as health services research.

Domestic violence in Australia: definition, prevalence and nature of presentation in clinical practice.

PubMed

Hegarty, K; Hindmarsh, E D; Gilles, M T

2000-10-02

Domestic violence is a complex pattern of behaviours that may include, in addition to physical acts of violence, sexual abuse and emotional abuse. Women experience domestic violence at far greater rates than men do, and women and children often live in fear as a result of the abuse that is used by men to maintain control over their partners. Domestic violence is a major public health problem and is very common in women attending clinical practice. Women present most commonly with a range of chronic symptoms to unsuspecting general practitioners, emergency department doctors or medical specialists. Women who have experienced partner abuse want to be asked about it and are more likely to disclose if asked in an empathic, non-judgemental way. Doctors can make a difference.

CXCL4-platelet factor 4, heparin-induced thrombocytopenia and cancer.

PubMed

Sandset, Per Morten

2012-04-01

Platelet factor 4 (CXCL4-PF4) is a chemokine that binds to and neutralizes heparin and other negatively charged proteoglycans, but is also involved in angiogenesis and cancer development. In some patients exposed to heparin, antibodies are generated against the CXCL-PF4/heparin complex that may activate platelets and coagulation and lead to thrombocytopenia and arterial or venous thrombosis, a condition commonly named heparin induced thrombocytopenia (HIT). HIT has been investigated in numerous clinical settings, but there is limited data on the epidemiology and phenotype of HIT in cancer patients. The present review describes the role of CXCL4-PF4 in cancer, the immunobiology, clinical presentation and diagnosis of HIT, and the specific problems faced in cancer patients. Copyright © 2012 Elsevier Ltd. All rights reserved.

Complex networks for data-driven medicine: the case of Class III dentoskeletal disharmony

NASA Astrophysics Data System (ADS)

Scala, A.; Auconi, P.; Scazzocchio, M.; Caldarelli, G.; McNamara, JA; Franchi, L.

2014-11-01

In the last decade, the availability of innovative algorithms derived from complexity theory has inspired the development of highly detailed models in various fields, including physics, biology, ecology, economy, and medicine. Due to the availability of novel and ever more sophisticated diagnostic procedures, all biomedical disciplines face the problem of using the increasing amount of information concerning each patient to improve diagnosis and prevention. In particular, in the discipline of orthodontics the current diagnostic approach based on clinical and radiographic data is problematic due to the complexity of craniofacial features and to the numerous interacting co-dependent skeletal and dentoalveolar components. In this study, we demonstrate the capability of computational methods such as network analysis and module detection to extract organizing principles in 70 patients with excessive mandibular skeletal protrusion with underbite, a condition known in orthodontics as Class III malocclusion. Our results could possibly constitute a template framework for organising the increasing amount of medical data available for patients’ diagnosis.

NMR study on the stabilization and chiral discrimination of sulforaphane enantiomers and analogues by cyclodextrins.

PubMed

Recio, Rocío; Elhalem, Eleonora; Benito, Juan M; Fernández, Inmaculada; Khiar, Noureddine

2018-05-01

Sulforaphane (SFN), a phytochemical isolated from broccoli, is an important antitumoral compound with additional beneficial effect on other important diseases. However, the chemical instability of SFN has hampered its clinical use. In order to circumvent this problem, we report the first comparative study on the inclusion complexes of SFN and SFN homologues with different cyclodextrins by NMR spectroscopy. From this study it has been shown that α-CD is the most indicated cyclodextrin for the stabilization of SFN and SFN homologues, and that the highest affinity constant is that of the isothiocyanate obtained from the wasabi. Furthermore, the study of the inclusion complexes of α-CD and the non-natural SFN and analogues with S absolute configuration at sulfur shows for the first time that α-CD is able to discriminate between the two enantiomers, with the natural R enantiomers forming the inclusion complexes with higher affinity. Copyright © 2017 Elsevier Ltd. All rights reserved.

Is High Fidelity Simulation the Most Effective Method for the Development of Non-Technical Skills in Nursing? A Review of the Current Evidence

PubMed Central

Lewis, Robin; Strachan, Alasdair; Smith, Michelle McKenzie

2012-01-01

Aim: To review the literature on the use of simulation in the development of non-technical skills in nursing Background: The potential risks to patients associated with learning 'at the bedside' are becoming increasingly unacceptable, and the search for innovative education and training methods that do not expose the patient to preventable errors continues. All the evidence shows that a significant proportion of adverse events in health care is caused by problems relating to the application of the 'non-technical' skills of communication, teamwork, leadership and decision-making. Results: Simulation is positively associated with significantly improved interpersonal communication skills at patient handover, and it has also been clearly shown to improve team behaviours in a wide variety of clinical contexts and clinical personnel, associated with improved team performance in the management of crisis situations. It also enables the effective development of transferable, transformational leadership skills, and has also been demonstrated to improve students' critical thinking and clinical reasoning in complex care situations, and to aid in the development of students' self-efficacy and confidence in their own clinical abilities. Conclusion: High fidelity simulation is able to provide participants with a learning environment in which to develop non-technical skills, that is safe and controlled so that the participants are able to make mistakes, correct those mistakes in real time and learn from them, without fear of compromising patient safety. Participants in simulation are also able to rehearse the clinical management of rare, complex or crisis situations in a valid representation of clinical practice, before practising on patients. PMID:22893783

Clinical trials bureaucracy: unintended consequences of well-intentioned policy.

PubMed

Califf, Robert M

2006-01-01

As randomized controlled trials have become the 'gold standard' for medical research, a complex regulatory structure for the conduct of clinical trials has emerged. However, this structure has not been adequately assessed to ensure that regulations governing human subjects research actually produce the desired effects. Our purpose is to identify some of the major shortcomings in the current regulatory system of human clinical trials oversight, and to propose some potential solutions to these problems. We discuss the evolution of the current US regulatory environment and its application in the context of several widely-used drug therapies. Despite numerous randomized controlled trials, performed within a structure of extensive documentation and data collection, serious shortcomings in a number of pharmaceutical therapies were not detected until after the drugs were approved and widely adopted by clinicians. The current system of regulatory bureaucracy in clinical trials has led to an extremely expensive research paradigm that, in spite of complex systems of oversight and exhaustive data collection, cannot be shown to adequately ensure the integrity of the research process and the protection of human research subjects. Some parts of the system, including Research Ethics Review Boards, may not be well-suited to carrying out their core mission of overseeing research conduct, and other aspects of clinical trials regulatory structure, such as monitoring/auditing review and adverse event reporting, may constitute a waste of money and resources. Misdirected data collection and adverse events reporting divert valuable resources and hamper development of large, simple clinical trials powered to definitively answer important research questions. Careful scrutiny of the utility of current or proposed regulatory schemes is required to ensure the integrity of human subjects research and to enhance the effectiveness of research dollars.

Word Problem Solving in Contemporary Math Education: A Plea for Reading Comprehension Skills Training

PubMed Central

Boonen, Anton J. H.; de Koning, Björn B.; Jolles, Jelle; van der Schoot, Menno

2016-01-01

Successfully solving mathematical word problems requires both mental representation skills and reading comprehension skills. In Realistic Math Education (RME), however, students primarily learn to apply the first of these skills (i.e., representational skills) in the context of word problem solving. Given this, it seems legitimate to assume that students from a RME curriculum experience difficulties when asked to solve semantically complex word problems. We investigated this assumption under 80 sixth grade students who were classified as successful and less successful word problem solvers based on a standardized mathematics test. To this end, students completed word problems that ask for both mental representation skills and reading comprehension skills. The results showed that even successful word problem solvers had a low performance on semantically complex word problems, despite adequate performance on semantically less complex word problems. Based on this study, we concluded that reading comprehension skills should be given a (more) prominent role during word problem solving instruction in RME. PMID:26925012

Word Problem Solving in Contemporary Math Education: A Plea for Reading Comprehension Skills Training.

PubMed

Boonen, Anton J H; de Koning, Björn B; Jolles, Jelle; van der Schoot, Menno

2016-01-01

Successfully solving mathematical word problems requires both mental representation skills and reading comprehension skills. In Realistic Math Education (RME), however, students primarily learn to apply the first of these skills (i.e., representational skills) in the context of word problem solving. Given this, it seems legitimate to assume that students from a RME curriculum experience difficulties when asked to solve semantically complex word problems. We investigated this assumption under 80 sixth grade students who were classified as successful and less successful word problem solvers based on a standardized mathematics test. To this end, students completed word problems that ask for both mental representation skills and reading comprehension skills. The results showed that even successful word problem solvers had a low performance on semantically complex word problems, despite adequate performance on semantically less complex word problems. Based on this study, we concluded that reading comprehension skills should be given a (more) prominent role during word problem solving instruction in RME.

[A clinical investigation of new patients who had already received treatment with dental implants at other clinics in seventeen years].

PubMed

Yukawa, Ken; Tachikawa, Noriko; Munakata, Motohiro; Shiota, Makoto; Kasugai, Shohei

2014-03-01

The purpose of this study was to investigate new patients who had already received treatment with dental implants. The subjects were patients who visited the clinic for oral implants at Tokyo Medical and Dental University Hospital from April 1995 to March 2012. The results were as follows: 1) Of the total number of patients, there were 2,419 patients (14.0%) with dental implants. 2) Of the 2,419 patients, 252 patients (10.4%) had been referred from operating doctors or operating clinics. 3) There were 1,516 (62.7%) patients with complaints related to the implant therapy. 4) There were 1,367 (56.5%) patients who had ill feelings toward their attending doctors. 5) There were 1,112 (46.0%) patients with biological complications. 6) Regarding patients with or without a referral from the doctor who had performed their dental implant, those patients who had been referred showed significantly higher occurrence of loss of implants, neurological symptoms, doctor's recommendation, prosthetic problems, and surgical problems. Almost implant therapies were treated with other treatments for natural teeth, including surgical treatment, prosthetic treatment, periodontal treatment and maintenance. These were too complex to enable the results to be forecast before treatment, therefore unpredictable symptoms often occur in patients with implant therapy. Informed consent including patient education is important, but the results of this study suggest that it is insufficient at present.

A problem solving and decision making toolbox for approaching clinical problems and decisions.

PubMed

Margolis, C; Jotkowitz, A; Sitter, H

2004-08-01

In this paper, we begin by presenting three real patients and then review all the practical conceptual tools that have been suggested for systematically analyzing clinical problems. Each of these conceptual tools (e.g. Evidence-Based Medicine, Clinical Practice Guidelines, Decision Analysis) deals mainly with a different type or aspect of clinical problems. We suggest that all of these conceptual tools can be thought of as belonging in the clinician's toolbox for solving clinical problems and making clinical decisions. A heuristic for guiding the clinician in using the tools is proposed. The heuristic is then used to analyze management of the three patients presented at the outset. Copyright 2004 Birkhäuser Verlag, Basel

[One-stage reconstruction of zygomatico-orbital complex with the use of implants of different origin].

PubMed

Menabde, G T; Gvenetadze, Z V; Atskvereli, L Sh

2009-03-01

Reconstruction of zygomatico-orbital complex remains as one of the troublesome and topical problems at steady posttraumatic deformations and fresh traumas of the mentioned region. The present work provides analysis of our own experience of surgical treatment of patients suffering from posttraumatic deformations and defects of zygomatico-orbital complex. The work was based on the results of examination and treatment of 33 patients who underwent an operation during the period from 2003 to 2008 years. Of 33, 21 patients were operated due to fresh traumas of the zygomatico-orbital region, and 12 - due to steady posttraumatic deformations of the mentioned region. Of 33 clinical cases, 19 patients underwent reconstruction of zygomatico-orbital complex with the use of implant. In 11 cases implants were perforated titanic plates, in 6 cases - bone cement (Surgical Simplex P), and in 2 cases - combination of titanic plates with bone cement. The results of our investigations have shown that one-stage reconstruction of zygomatico-orbital complex with the use of titanic plates and bone cement liquidates functional and cosmetic disorders. It has been suggested that the use of elaborated complex approaches in treatment of posttraumatic deformations and fresh traumas of zygomatico-orbital region is reasonable and acceptable.

The transition from learner to provider/teacher: the learning needs of new orthopaedic consultants.

PubMed

McKinstry, Brian; Macnicol, Malcolm; Elliot, Katy; Macpherson, Stuart

2005-05-17

Given the relatively sudden change from learner to teacher-provider that new consultants experience and the likely clinical and managerial challenges this may pose, there is a relative dearth of research into the problems they may have in relation to their new roles, or how supported they feel by senior colleagues acting in a mentoring role. This research sought to determine new consultants views on the quality and relevance of their training, its relationship to their confidence in clinical and managerial skills and their views on mentorship by senior colleagues. Detailed postal questionnaire to new consultants using open and closed questions. Open questionnaire to established consultants to validate new consultant responses. Respondents felt their clinical training was good and were generally confident in most clinical skills although some perceived deficiencies in more complex procedures and specialist areas. Most lacked confidence in many managerial skills. These perceptions were verified by established consultants. Although no relationship was found between total training time or quality of training with confidence, extra training in specific sub-specialities improved confidence in these areas. While most established consultants thought that mentorship would be useful for new consultants, only 52% of them shared this view. Training and experience in management should be given greater emphasis. There may be a need for specific, targeted training in complex procedures for doctors who experience lack of confidence in these areas. Mentorship should be offered to new consultants and recognised in the job-plan of the new consultant contract.

A theory-based educational intervention targeting nurses' attitudes and knowledge concerning cancer-related pain management: a study protocol of a quasi-experimental design.

PubMed

Borglin, Gunilla; Gustafsson, Markus; Krona, Hans

2011-09-23

Pain is one of the most frequent problems among patients diagnosed with cancer. Despite the availability of effective pharmacological treatments, this group of patients often receives less than optimal treatment. Research into nurses' pain management highlights certain factors, such as lack of knowledge and attitudes and inadequate procedures for systematic pain assessment, as common barriers to effective pain management. However, educational interventions targeting nurses' pain management have shown promise. As cancer-related pain is also known to have a negative effect on vital aspects of the patient's life, as well as being commonly associated with problems such as sleep, fatigue, depression and anxiety, further development of knowledge within this area is warranted. A quasi-experimental study design will be used to investigate whether the implementation of guidelines for systematic daily pain assessments following a theory-based educational intervention will result in an improvement in knowledge and attitude among nurses. A further aim is to investigate whether the intervention that targets nurses' behaviour will improve hospital patients' perception of pain. Data regarding nurses' knowledge and attitudes to pain (primary outcome), patient perception regarding pain (secondary outcome), together with socio-demographic variables, will be collected at baseline and at four weeks and 12 weeks following the intervention. Nursing care is nowadays acknowledged as an increasingly complicated activity and "nursing complexity is such that it can be seen as the quintessential complex intervention." To be able to change and improve clinical practice thus requires multiple points of attack appropriate to meet complex challenges. Consequently, we expect the theory-based intervention used in our quasi-experimental study to improve care as well as quality of life for this group of patients and we also envisage that evidence-based guidelines targeting this patient group's pain will be implemented more widely. ClinicalTrials.gov NCT01313234.

Mental health of primary caregivers for children and adolescents with HIV/AIDS in Cuba.

PubMed

Santiesteban, Yasel; Castro, Marta; Calvo, Marina

2012-04-01

An HIV diagnosis, like that of any another chronic illness, alters family dynamics. Although the whole family is affected, usually only one member is the primary caregiver of the sick person. Children and adolescents with HIV/AIDS need care according to their physical, psychological and social needs, requiring responsible caregivers who maintain adequate physical and mental health. To describe general mental health characteristics of primary caregivers of Cuban children and adolescents from across the country diagnosed with HIV/AIDS at the Pedro Kourí Tropical Medicine Institute. A descriptive study was carried out from November 2009 through March 2010. Twenty-six caregivers met inclusion criteria and 13 participated. A psychological assessment was made of each caregiver's mental health, including both externally evaluated and self reported factors associated with physical or psychological problems. Clinical interview and observation, psychiatric examination and various psychological tests were used. A simple descriptive analysis of caregiver characteristics, qualitative information and test results was made. Most caregivers were women, infected with HIV/AIDS themselves, unemployed and without a partner. They presented symptoms of anxiety but no clinical psychiatric diagnoses. The study group reported dissatisfaction with family functioning and partner relationships, as well as problems related to HIV and poor employment prospects. Caregivers studied described complex intra- and interpersonal life dynamics influenced by their HIV infection. Their mental health status, evaluated through a combination of objective and subjective factors reveals a complex reality, indicating the need for a more comprehensive and efficient approach to caregivers' health care, integrating attention to both physical and mental health.

Binary optimization for source localization in the inverse problem of ECG.

PubMed

Potyagaylo, Danila; Cortés, Elisenda Gil; Schulze, Walther H W; Dössel, Olaf

2014-09-01

The goal of ECG-imaging (ECGI) is to reconstruct heart electrical activity from body surface potential maps. The problem is ill-posed, which means that it is extremely sensitive to measurement and modeling errors. The most commonly used method to tackle this obstacle is Tikhonov regularization, which consists in converting the original problem into a well-posed one by adding a penalty term. The method, despite all its practical advantages, has however a serious drawback: The obtained solution is often over-smoothed, which can hinder precise clinical diagnosis and treatment planning. In this paper, we apply a binary optimization approach to the transmembrane voltage (TMV)-based problem. For this, we assume the TMV to take two possible values according to a heart abnormality under consideration. In this work, we investigate the localization of simulated ischemic areas and ectopic foci and one clinical infarction case. This affects only the choice of the binary values, while the core of the algorithms remains the same, making the approximation easily adjustable to the application needs. Two methods, a hybrid metaheuristic approach and the difference of convex functions (DC), algorithm were tested. For this purpose, we performed realistic heart simulations for a complex thorax model and applied the proposed techniques to the obtained ECG signals. Both methods enabled localization of the areas of interest, hence showing their potential for application in ECGI. For the metaheuristic algorithm, it was necessary to subdivide the heart into regions in order to obtain a stable solution unsusceptible to the errors, while the analytical DC scheme can be efficiently applied for higher dimensional problems. With the DC method, we also successfully reconstructed the activation pattern and origin of a simulated extrasystole. In addition, the DC algorithm enables iterative adjustment of binary values ensuring robust performance.

What happens to women who sell sex? Report of a unique occupational cohort.

PubMed

Ward, H; Day, S

2006-10-01

Sex work has been seen as both a health and a social problem. However, there is a paucity of evidence on the longer term impact on health. We explored the health and career paths over a period of 15 years among women who have worked in the sex industry. A longitudinal study of sex workers recruited between 1986 and 1993 and followed for 15 years. Outcome data were obtained through interview, clinic records, or third parties. Clinic and community settings in London. We obtained outcome data on 130 (37%) of the original cohort of 354 women, with a combined follow up of 1247 years. Vital status, most recent occupation, duration of sex work, sexually transmitted infections (STI), major health problems. The majority (73/124, 59%) were still in the sex industry and had sold sex for a mean of 13.6 years. There were six deaths, a mortality of 4.8 per 1000 person years. Surviving women had a high cumulative risk (110 of 118, 93%) of STI. Past gonorrhoea was associated with pelvic inflammatory disease (RR 2.28, 95% CI 1.12 to 4.66) and infertility (RR 10.9, 95% CI 1.5 to 77.3). Other outcomes included mental health problems (38 of 97, 40%) and addiction (46 of 72, 64%). There were no significant differences in health outcomes between women who were still in the sex industry and those who had stopped. There was a high level of occupational mobility, and 31 women (of 84, 37%) had completed vocational or higher education, including eight to postgraduate level. Sex work is associated with excess mortality and morbidity including the sequelae of STI, mental health problems, and substance misuse. The relation between these health problems and sex work is complex.

Understanding the determinants of problem-solving behavior in a complex environment

NASA Technical Reports Server (NTRS)

Casner, Stephen A.

1994-01-01

It is often argued that problem-solving behavior in a complex environment is determined as much by the features of the environment as by the goals of the problem solver. This article explores a technique to determine the extent to which measured features of a complex environment influence problem-solving behavior observed within that environment. In this study, the technique is used to determine how complex flight deck and air traffic control environment influences the strategies used by airline pilots when controlling the flight path of a modern jetliner. Data collected aboard 16 commercial flights are used to measure selected features of the task environment. A record of the pilots' problem-solving behavior is analyzed to determine to what extent behavior is adapted to the environmental features that were measured. The results suggest that the measured features of the environment account for as much as half of the variability in the pilots' problem-solving behavior and provide estimates on the probable effects of each environmental feature.

Cardiac examination and the effect of dual-processing instruction in a cardiopulmonary simulator.

PubMed

Sibbald, Matt; McKinney, James; Cavalcanti, Rodrigo B; Yu, Eric; Wood, David A; Nair, Parvathy; Eva, Kevin W; Hatala, Rose

2013-08-01

Use of dual-processing has been widely touted as a strategy to reduce diagnostic error in clinical medicine. However, this strategy has not been tested among medical trainees with complex diagnostic problems. We sought to determine whether dual-processing instruction could reduce diagnostic error across a spectrum of experience with trainees undertaking cardiac physical exam. Three experiments were conducted using a similar design to teach cardiac physical exam using a cardiopulmonary simulator. One experiment was conducted in each of three groups: experienced, intermediate and novice trainees. In all three experiments, participants were randomized to receive undirected or dual-processing verbal instruction during teaching, practice and testing phases. When tested, dual-processing instruction did not change the probability assigned to the correct diagnosis in any of the three experiments. Among intermediates, there was an apparent interaction between the diagnosis tested and the effect of dual-processing instruction. Among relative novices, dual processing instruction may have dampened the harmful effect of a bias away from the correct diagnosis. Further work is needed to define the role of dual-processing instruction to reduce cognitive error. This study suggests that it cannot be blindly applied to complex diagnostic problems such as cardiac physical exam.

The complex array of antecedents of depression in women with physical disabilities: implications for clinicians.

PubMed

Nosek, Margaret A; Hughes, Rosemary B; Robinson-Whelen, Susan

2008-01-01

This article discusses the complex interrelation of elements of the physical, psychological, social, and environmental life context of women with physical disabilities and the association of these elements with significant disparities in rates of depression and access to mental health care for this population. Literature and concept review. High rates of depression in women with physical disabilities are well documented in the literature. Many elements that are disproportionately common in the lives of women with physical disabilities, including socio-economic disadvantage, functional limitations, pain and other chronic health conditions, poor diet, physical inactivity, smoking, violence, low self-esteem, sexuality problems, chronic stress, environmental barriers, and barriers to health care, have also been linked with higher rates of depression and depressive symptomatology. Depression self-management interventions tailored for women with disabilities have been developed and proven effective. Many women who must deal with the stresses surrounding an array of health problems may experience symptoms of depression without necessarily meeting the criteria for clinical depression. Psychologists, counselors, primary care physicians, specialists, and other medical and rehabilitation professionals are challenged to recognize the symptoms of depression in women with physical disabilities and assist them in obtaining appropriate psychological and pharmacological interventions.

A Critical Review on Clinical Application of Separation Techniques for Selective Recognition of Uracil and 5-Fluorouracil.

PubMed

Pandey, Khushaboo; Dubey, Rama Shankar; Prasad, Bhim Bali

2016-03-01

The most important objectives that are frequently found in bio-analytical chemistry involve applying tools to relevant medical/biological problems and refining these applications. Developing a reliable sample preparation step, for the medical and biological fields is another primary objective in analytical chemistry, in order to extract and isolate the analytes of interest from complex biological matrices. Since, main inborn errors of metabolism (IEM) diagnosable through uracil analysis and the therapeutic monitoring of toxic 5-fluoruracil (an important anti-cancerous drug) in dihydropyrimidine dehydrogenase deficient patients, require an ultra-sensitive, reproducible, selective, and accurate analytical techniques for their measurements. Therefore, keeping in view, the diagnostic value of uracil and 5-fluoruracil measurements, this article refines several analytical techniques involved in selective recognition and quantification of uracil and 5-fluoruracil from biological and pharmaceutical samples. The prospective study revealed that implementation of molecularly imprinted polymer as a solid-phase material for sample preparation and preconcentration of uracil and 5-fluoruracil had proven to be effective as it could obviates problems related to tedious separation techniques, owing to protein binding and drastic interferences, from the complex matrices in real samples such as blood plasma, serum samples.

On Complex Water Conflicts: Role of Enabling Conditions for Pragmatic Resolution

NASA Astrophysics Data System (ADS)

Islam, S.; Choudhury, E.

2016-12-01

Many of our current and emerging water problems are interconnected and cross boundaries, domains, scales, and sectors. These boundary crossing water problems are neither static nor linear; but often are interconnected nonlinearly with other problems and feedback. The solution space for these complex problems - involving interdependent variables, processes, actors, and institutions - can't be pre-stated. We need to recognize the disconnect among values, interests, and tools as well as problems, policies, and politics. Scientific and technological solutions are desired for efficiency and reliability, but need to be politically feasible and actionable. Governing and managing complex water problems require difficult tradeoffs in exploring and sharing benefits and burdens through carefully crafted negotiation processes. The crafting of such negotiation process, we argue, constitutes a pragmatic approach to negotiation - one that is based on the identification of enabling conditions - as opposed to mechanistic casual explanations, and rooted in contextual conditions to specify and ensure the principles of equity and sustainability. We will use two case studies to demonstrate the efficacy of the proposed principled pragmatic approcah to address complex water problems.

Using task analysis in healthcare design to improve clinical efficiency.

PubMed

Lu, Jun; Hignett, Sue

2009-01-01

To review the functionality of the proposed soiled workroom design for efficient and safe clinical activities. As part of a hospital refurbishment program, the planning team of a United Kingdom National Health Service hospital requested a review of a proposed standardized room design. A 7-day observational study was conducted in five clinical departments at three hospitals. Link analysis was used to record and analyze the movements among components, i.e., nursing staff, equipment/devices, and furniture. Fifty-four observations were recorded for 18 clinical tasks. The most frequent tasks were the disposal of urine and used urine bottles, and returning used commode chairs. Minor recommendations were made to improve the proposed design, and major revisions were suggested to address functionality problems. It was found that the proposed design did not offer the optimal layout for efficient and safe clinical activities. Link analysis was found to be effective for plotting the movements of the staff and accounting for the complexity of tasks. This ergonomic method, in combination with observational field studies, provided a simple and effective way to determine functional space requirements for clinical activities and should be used in all healthcare building design projects.

The 3D elliptic restricted three-body problem: periodic orbits which bifurcate from limiting restricted problems. Complex instability

NASA Astrophysics Data System (ADS)

Ollé, Mercè; Pacha, Joan R.

1999-11-01

In the present work we use certain isolated symmetric periodic orbits found in some limiting Restricted Three-Body Problems to obtain, by numerical continuation, families of symmetric periodic orbits of the more general Spatial Elliptic Restricted Three Body Problem. In particular, the Planar Isosceles Restricted Three Body Problem, the Sitnikov Problem and the MacMillan problem are considered. A stability study for the periodic orbits of the families obtained - specially focused to detect transitions to complex instability - is also made.

Complex fuzzy soft expert sets

NASA Astrophysics Data System (ADS)

Selvachandran, Ganeshsree; Hafeed, Nisren A.; Salleh, Abdul Razak

2017-04-01

Complex fuzzy sets and its accompanying theory although at its infancy, has proven to be superior to classical type-1 fuzzy sets, due its ability in representing time-periodic problem parameters and capturing the seasonality of the fuzziness that exists in the elements of a set. These are important characteristics that are pervasive in most real world problems. However, there are two major problems that are inherent in complex fuzzy sets: it lacks a sufficient parameterization tool and it does not have a mechanism to validate the values assigned to the membership functions of the elements in a set. To overcome these problems, we propose the notion of complex fuzzy soft expert sets which is a hybrid model of complex fuzzy sets and soft expert sets. This model incorporates the advantages of complex fuzzy sets and soft sets, besides having the added advantage of allowing the users to know the opinion of all the experts in a single model without the need for any additional cumbersome operations. As such, this model effectively improves the accuracy of representation of problem parameters that are periodic in nature, besides having a higher level of computational efficiency compared to similar models in literature.

Thresholds of Knowledge Development in Complex Problem Solving: A Multiple-Case Study of Advanced Learners' Cognitive Processes

ERIC Educational Resources Information Center

Bogard, Treavor; Liu, Min; Chiang, Yueh-hui Vanessa

2013-01-01

This multiple-case study examined how advanced learners solved a complex problem, focusing on how their frequency and application of cognitive processes contributed to differences in performance outcomes, and developing a mental model of a problem. Fifteen graduate students with backgrounds related to the problem context participated in the study.…

The Animal Model of Spinal Cord Injury as an Experimental Pain Model

PubMed Central

Nakae, Aya; Nakai, Kunihiro; Yano, Kenji; Hosokawa, Ko; Shibata, Masahiko; Mashimo, Takashi

2011-01-01

Pain, which remains largely unsolved, is one of the most crucial problems for spinal cord injury patients. Due to sensory problems, as well as motor dysfunctions, spinal cord injury research has proven to be complex and difficult. Furthermore, many types of pain are associated with spinal cord injury, such as neuropathic, visceral, and musculoskeletal pain. Many animal models of spinal cord injury exist to emulate clinical situations, which could help to determine common mechanisms of pathology. However, results can be easily misunderstood and falsely interpreted. Therefore, it is important to fully understand the symptoms of human spinal cord injury, as well as the various spinal cord injury models and the possible pathologies. The present paper summarizes results from animal models of spinal cord injury, as well as the most effective use of these models. PMID:21436995

The Complex Route to Success: Complex Problem-Solving Skills in the Prediction of University Success

ERIC Educational Resources Information Center

Stadler, Matthias J.; Becker, Nicolas; Greiff, Samuel; Spinath, Frank M.

2016-01-01

Successful completion of a university degree is a complex matter. Based on considerations regarding the demands of acquiring a university degree, the aim of this paper was to investigate the utility of complex problem-solving (CPS) skills in the prediction of objective and subjective university success (SUS). The key finding of this study was that…

Building the chronic kidney disease management team.

PubMed

Spry, Leslie

2008-01-01

The need to be efficient and the demands for performance-based service are changing how nephrologists deliver care. Chronic kidney disease (CKD) occurs in patients with complex medical and social problems. CKD management requires that multidisciplinary professionals provide patient education, disease management, and psychosocial support. To remain cost-efficient, many physicians are training and supervising midlevel practitioners in the delivery of specialized health care. Specialized care that meets present CKD patient needs is best delivered in a CKD clinic. Three models of CKD clinic are identified: (1) anemia management CKD clinic, (2) the basic CKD clinic, and (3) the comprehensive CKD clinic. Each clinic model is based on critical elements of staffing, billable services, and patient-focused health care. Billable services are anemia-management services, physician services that may be provided by midlevel practitioners, and medical nutrition therapy. In some cases, social worker services may be billable. Building a patient-focused clinic that offers CKD management requires planning, familiarity with federal regulations and statutes, and skillful practitioners. Making services cost-efficient and outcome oriented requires careful physician leadership, talented midlevel practitioners, and billing professionals who understand the goals of the CKD clinic. As Medicare payment reforms evolve, a well-organized CKD program can be well poised to meet the requirements of payers and congressional mandates for performance-based purchasing.

Comparison of antibiotic resistance patterns in collections of Escherichia coli and Proteus mirabilis uropathogenic strains.

PubMed

Adamus-Bialek, Wioletta; Zajac, Elzbieta; Parniewski, Pawel; Kaca, Wieslaw

2013-04-01

Escherichia coli and Proteus mirabilis are important urinary tract pathogens. The constant increase in the antibiotic resistance of clinical bacterial strains has become an important clinical problem. The aim of this study was to compare the antibiotic resistance of 141 clinical (Sweden and Poland) and 42 laboratory (Czech Republic) P. mirabilis strains and 129 clinical (Poland) uropathogenic E. coli strains. The proportion of unique versus diverse patterns in Swedish clinical and laboratory P. mirabilis strain collections was comparable. Notably, a similar proportion of unique versus diverse patterns was observed in Polish clinical P. mirabilis and E. coli strain collections. Mathematical models of the antibiotic resistance of E. coli and P. mirabilis strains based on Kohonen networks and association analysis are presented. In contrast to the three clinical strain collections, which revealed complex associations with the antibiotics tested, laboratory P. mirabilis strains provided simple antibiotic association diagrams. The monitoring of antibiotic resistance patterns of clinical E. coli and P. mirabilis strains plays an important role in the treatment procedures for urinary tract infections and is important in the context of the spreading drug resistance in uropathogenic strain populations. The adaptability and flexibility of the genomes of E. coli and P. mirabilis strains are discussed.

Cultivating interpretive thinking through enacting narrative pedagogy.

PubMed

Scheckel, Martha M; Ironside, Pamela M

2006-01-01

Teachers and educational researchers in nursing have persisted in their attempts to teach students critical thinking and to evaluate the effectiveness of these efforts. Yet, despite the plethora of studies investigating critical thinking, there is a paucity of research providing evidence that teachers' efforts improve students' thinking. The purpose of this interpretive phenomenological study is to explicate how students' thinking can be extended when teachers use Narrative Pedagogy. Specifically, the theme Cultivating Interpretive Thinking refers to how teachers' use of Narrative Pedagogy moves beyond the critical thinking movement's emphasis on analytical thinking (i.e., problem solving). Cultivating Interpretive Thinking offers an innovative approach for teaching and learning thinking that attends to students' embodied, reflective, and pluralistic thinking experiences. Teachers who cultivate interpretive thinking add complexity to students' thinking to better prepare them for challenging, complex, and unpredictable clinical environments.

An Efficient Pattern Mining Approach for Event Detection in Multivariate Temporal Data

PubMed Central

Batal, Iyad; Cooper, Gregory; Fradkin, Dmitriy; Harrison, James; Moerchen, Fabian; Hauskrecht, Milos

2015-01-01

This work proposes a pattern mining approach to learn event detection models from complex multivariate temporal data, such as electronic health records. We present Recent Temporal Pattern mining, a novel approach for efficiently finding predictive patterns for event detection problems. This approach first converts the time series data into time-interval sequences of temporal abstractions. It then constructs more complex time-interval patterns backward in time using temporal operators. We also present the Minimal Predictive Recent Temporal Patterns framework for selecting a small set of predictive and non-spurious patterns. We apply our methods for predicting adverse medical events in real-world clinical data. The results demonstrate the benefits of our methods in learning accurate event detection models, which is a key step for developing intelligent patient monitoring and decision support systems. PMID:26752800

Spirituality and Religion in Pain and Pain Management

PubMed Central

Dedeli, Ozden; Kaptan, Gulten

2013-01-01

Pain relief is a management problem for many patients, their families, and the medical professionals caring for them. Although everyone experiences pain to some degree, responses to it vary from one person to another. Recognizing and specifying someone else’s pain is clinically a well know challenge. Research on the biology and neurobiology of pain has given us a relationship between spirituality and pain. There is growing recognition that persistent pain is a complex and multidimensional experience stemming from the interrelations among biological, psychological, social, and spiritual factors. Patients with pain use a number of cognitive and behavioral strategies to cope with their pain, including religious/spiritual factors, such as prayers, and seeking spiritual support to manage their pain. This article provides an overview of the complex phenomenon of pain, with a focus on spiritual and religious issues in pain management. PMID:26973914

A complexity theory model in science education problem solving: random walks for working memory and mental capacity.

PubMed

Stamovlasis, Dimitrios; Tsaparlis, Georgios

2003-07-01

The present study examines the role of limited human channel capacity from a science education perspective. A model of science problem solving has been previously validated by applying concepts and tools of complexity theory (the working memory, random walk method). The method correlated the subjects' rank-order achievement scores in organic-synthesis chemistry problems with the subjects' working memory capacity. In this work, we apply the same nonlinear approach to a different data set, taken from chemical-equilibrium problem solving. In contrast to the organic-synthesis problems, these problems are algorithmic, require numerical calculations, and have a complex logical structure. As a result, these problems cause deviations from the model, and affect the pattern observed with the nonlinear method. In addition to Baddeley's working memory capacity, the Pascual-Leone's mental (M-) capacity is examined by the same random-walk method. As the complexity of the problem increases, the fractal dimension of the working memory random walk demonstrates a sudden drop, while the fractal dimension of the M-capacity random walk decreases in a linear fashion. A review of the basic features of the two capacities and their relation is included. The method and findings have consequences for problem solving not only in chemistry and science education, but also in other disciplines.

How students process equations in solving quantitative synthesis problems? Role of mathematical complexity in students' mathematical performance

NASA Astrophysics Data System (ADS)

Ibrahim, Bashirah; Ding, Lin; Heckler, Andrew F.; White, Daniel R.; Badeau, Ryan

2017-12-01

We examine students' mathematical performance on quantitative "synthesis problems" with varying mathematical complexity. Synthesis problems are tasks comprising multiple concepts typically taught in different chapters. Mathematical performance refers to the formulation, combination, and simplification of equations. Generally speaking, formulation and combination of equations require conceptual reasoning; simplification of equations requires manipulation of equations as computational tools. Mathematical complexity is operationally defined by the number and the type of equations to be manipulated concurrently due to the number of unknowns in each equation. We use two types of synthesis problems, namely, sequential and simultaneous tasks. Sequential synthesis tasks require a chronological application of pertinent concepts, and simultaneous synthesis tasks require a concurrent application of the pertinent concepts. A total of 179 physics major students from a second year mechanics course participated in the study. Data were collected from written tasks and individual interviews. Results show that mathematical complexity negatively influences the students' mathematical performance on both types of synthesis problems. However, for the sequential synthesis tasks, it interferes only with the students' simplification of equations. For the simultaneous synthesis tasks, mathematical complexity additionally impedes the students' formulation and combination of equations. Several reasons may explain this difference, including the students' different approaches to the two types of synthesis problems, cognitive load, and the variation of mathematical complexity within each synthesis type.

Problem-gambling severity, suicidality and DSM-IV Axis II personality disorders.

PubMed

Ronzitti, Silvia; Kraus, Shane W; Hoff, Rani A; Clerici, Massimo; Potenza, Marc N

2018-07-01

Despite the strong associations between personality disorders and problem/pathological gambling, few studies have investigated the relationships between personality disorders, problem-gambling severity and suicidal thoughts/behaviors. We examined the relationships between problem-gambling severity and personality disorders among individuals with differing levels of suicidality (none, thoughts alone, attempts). We analyzed data from 13,543 participants of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) study. First, differences in sociodemographic characteristics and prevalence of personality disorders were analyzed according to problem-gambling severity and suicidality status. Second, we performed a logistic regression to assess among the relationship between problem-gambling severity and DSM-IV Axis II psychopathology according to suicidality level. At-risk or problem/pathological gambling groups showed higher rates of a wide range of personality disorders compared to non-gamblers. Logistic regression showed that at-risk pathological gamblers had a higher odds ratio for any personality disorder in the group with no history of suicidality, particularly for cluster-B personality disorders. Odds ratio interaction analysis identified the relationship between problem-gambling severity and personality disorders, particularly those in cluster B, differ according to suicidality status. Our findings suggest a complex relationship between suicidality, problem-gambling severity and personality disorders. The stronger relationship between problem-gambling severity and personality disorders in people with no suicidality as compared to some suicidality suggests that some of the relationship between greater problem-gambling severity and Axis II psychopathology is accounted for by increased suicidality. The findings have implications for clinical interventions targeting suicidality in individuals with gambling disorders. Published by Elsevier Ltd.

Can Undergraduates Be Transdisciplinary? Promoting Transdisciplinary Engagement through Global Health Problem-Based Learning

ERIC Educational Resources Information Center

Hay, M. Cameron

2017-01-01

Undergraduate student learning focuses on the development of disciplinary strength in majors and minors so that students gain depth in particular fields, foster individual expertise, and learn problem solving from disciplinary perspectives. However, the complexities of real-world problems do not respect disciplinary boundaries. Complex problems…

The Process of Solving Complex Problems

ERIC Educational Resources Information Center

Fischer, Andreas; Greiff, Samuel; Funke, Joachim

2012-01-01

This article is about Complex Problem Solving (CPS), its history in a variety of research domains (e.g., human problem solving, expertise, decision making, and intelligence), a formal definition and a process theory of CPS applicable to the interdisciplinary field. CPS is portrayed as (a) knowledge acquisition and (b) knowledge application…

Communities of Practice: A New Approach to Solving Complex Educational Problems

ERIC Educational Resources Information Center

Cashman, J.; Linehan, P.; Rosser, M.

2007-01-01

Communities of Practice offer state agency personnel a promising approach for engaging stakeholder groups in collaboratively solving complex and, often, persistent problems in special education. Communities of Practice can help state agency personnel drive strategy, solve problems, promote the spread of best practices, develop members'…

6 Essential Questions for Problem Solving

ERIC Educational Resources Information Center

Kress, Nancy Emerson

2017-01-01

One of the primary expectations that the author has for her students is for them to develop greater independence when solving complex and unique mathematical problems. The story of how the author supports her students as they gain confidence and independence with complex and unique problem-solving tasks, while honoring their expectations with…

Students' and Teachers' Conceptual Metaphors for Mathematical Problem Solving

ERIC Educational Resources Information Center

Yee, Sean P.

2017-01-01

Metaphors are regularly used by mathematics teachers to relate difficult or complex concepts in classrooms. A complex topic of concern in mathematics education, and most STEM-based education classes, is problem solving. This study identified how students and teachers contextualize mathematical problem solving through their choice of metaphors.…

How Students Process Equations in Solving Quantitative Synthesis Problems? Role of Mathematical Complexity in Students' Mathematical Performance

ERIC Educational Resources Information Center

Ibrahim, Bashirah; Ding, Lin; Heckler, Andrew F.; White, Daniel R.; Badeau, Ryan

2017-01-01

We examine students' mathematical performance on quantitative "synthesis problems" with varying mathematical complexity. Synthesis problems are tasks comprising multiple concepts typically taught in different chapters. Mathematical performance refers to the formulation, combination, and simplification of equations. Generally speaking,…

42 CFR 493.1415 - Condition: Laboratories performing moderate complexity testing; clinical consultant.

Code of Federal Regulations, 2010 CFR

2010-10-01

... complexity testing; clinical consultant. 493.1415 Section 493.1415 Public Health CENTERS FOR MEDICARE... § 493.1415 Condition: Laboratories performing moderate complexity testing; clinical consultant. The laboratory must have a clinical consultant who meets the qualification requirements of § 493.1417 of this...

The effects of monitoring environment on problem-solving performance.

PubMed

Laird, Brian K; Bailey, Charles D; Hester, Kim

2018-01-01

While effective and efficient solving of everyday problems is important in business domains, little is known about the effects of workplace monitoring on problem-solving performance. In a laboratory experiment, we explored the monitoring environment's effects on an individual's propensity to (1) establish pattern solutions to problems, (2) recognize when pattern solutions are no longer efficient, and (3) solve complex problems. Under three work monitoring regimes-no monitoring, human monitoring, and electronic monitoring-114 participants solved puzzles for monetary rewards. Based on research related to worker autonomy and theory of social facilitation, we hypothesized that monitored (versus non-monitored) participants would (1) have more difficulty finding a pattern solution, (2) more often fail to recognize when the pattern solution is no longer efficient, and (3) solve fewer complex problems. Our results support the first two hypotheses, but in complex problem solving, an interaction was found between self-assessed ability and the monitoring environment.

Teaching Problem Solving; the Effect of Algorithmic and Heuristic Problem Solving Training in Relation to Task Complexity and Relevant Aptitudes.

ERIC Educational Resources Information Center

de Leeuw, L.

Sixty-four fifth and sixth-grade pupils were taught number series extrapolation by either an algorithm, fully prescribed problem-solving method or a heuristic, less prescribed method. The trained problems were within categories of two degrees of complexity. There were 16 subjects in each cell of the 2 by 2 design used. Aptitude Treatment…

The weak relationship between anatomy competence and clinical skills in junior medical students.

PubMed

Schoeman, Scarpa; Chandratilake, Madawa

2012-01-01

In modern curricula, the early integration of anatomy and clinical skills education at undergraduate level is seen as important. However, the direct relationship between medical students' competence in anatomy, and their clinical proficiency during early undergraduate years, has scarcely been studied. In this study, the marks for anatomy and clinical skills of three consecutive cohorts of medical students (n = 538 in total) during their first two years were correlated. The anatomy competence was measured using a new marker, the Anatomy Competence Score (ACS) which was calculated with equal contributions from theory knowledge and its practical and clinical application. Proficiency in clinical skills was determined by OSCE performance marks for stations which examined physical examination and practical procedural skills. The possible compounding effect of students' general academic ability was investigated by using the overall performance mark for each student based on their performance in all subjects over the first two years of the medical curriculum. We found that the correlation between anatomy and clinical skills marks was weak to moderate. However, this correlation was virtually nullified once the effect of academic ability was accounted for. Although these findings suggest that anatomy education does not compliment early clinical education, the lack of complexity of clinical problems used in clinical skills assessments (OSCEs) during the early stages may well be the primary contributing factor to this finding. Copyright © 2012 American Association of Anatomists.

Evidence - competence - discourse: the theoretical framework of the multi-centre clinical ethics support project METAP.

PubMed

Reiter-Theil, Stella; Mertz, Marcel; Schürmann, Jan; Stingelin Giles, Nicola; Meyer-Zehnder, Barbara

2011-09-01

In this paper we assume that 'theory' is important for Clinical Ethics Support Services (CESS). We will argue that the underlying implicit theory should be reflected. Moreover, we suggest that the theoretical components on which any clinical ethics support (CES) relies should be explicitly articulated in order to enhance the quality of CES. A theoretical framework appropriate for CES will be necessarily complex and should include ethical (both descriptive and normative), metaethical and organizational components. The various forms of CES that exist in North-America and in Europe show their underlying theory more or less explicitly, with most of them referring to some kind of theoretical components including 'how-to' questions (methodology), organizational issues (implementation), problem analysis (phenomenology or typology of problems), and related ethical issues such as end-of-life decisions (major ethical topics). In order to illustrate and explain the theoretical framework that we are suggesting for our own CES project METAP, we will outline this project which has been established in a multi-centre context in several healthcare institutions. We conceptualize three 'pillars' as the major components of our theoretical framework: (1) evidence, (2) competence, and (3) discourse. As a whole, the framework is aimed at developing a foundation of our CES project METAP. We conclude that this specific integration of theoretical components is a promising model for the fruitful further development of CES. © 2011 Blackwell Publishing Ltd.

Simplifying the complexity surrounding ICU work processes--identifying the scope for information management in ICU settings.

PubMed

Munir, Samina K; Kay, Stephen

2005-08-01

A multi-site study, conducted in two English and two Danish intensive care units, investigates the complexity of work processes in intensive care, and the implications of this complexity for information management with regards to clinical information systems. Data were collected via observations, shadowing of clinical staff, interviews and questionnaires. The construction of role activity diagrams enabled the capture of critical care work processes. Upon analysing these diagrams, it was found that intensive care work processes consist of 'simplified-complexity', these processes are changed with the introduction of information systems for the everyday use and management of all clinical information. The prevailing notion of complexity surrounding critical care clinical work processes was refuted and found to be misleading; in reality, it is not the work processes that cause the complexity, the complexity is rooted in the way in which clinical information is used and managed. This study emphasises that the potential for clinical information systems that consider integrating all clinical information requirements is not only immense but also very plausible.

Automating Construction of Machine Learning Models With Clinical Big Data: Proposal Rationale and Methods

PubMed Central

Stone, Bryan L; Johnson, Michael D; Tarczy-Hornoch, Peter; Wilcox, Adam B; Mooney, Sean D; Sheng, Xiaoming; Haug, Peter J; Nkoy, Flory L

2017-01-01

Background To improve health outcomes and cut health care costs, we often need to conduct prediction/classification using large clinical datasets (aka, clinical big data), for example, to identify high-risk patients for preventive interventions. Machine learning has been proposed as a key technology for doing this. Machine learning has won most data science competitions and could support many clinical activities, yet only 15% of hospitals use it for even limited purposes. Despite familiarity with data, health care researchers often lack machine learning expertise to directly use clinical big data, creating a hurdle in realizing value from their data. Health care researchers can work with data scientists with deep machine learning knowledge, but it takes time and effort for both parties to communicate effectively. Facing a shortage in the United States of data scientists and hiring competition from companies with deep pockets, health care systems have difficulty recruiting data scientists. Building and generalizing a machine learning model often requires hundreds to thousands of manual iterations by data scientists to select the following: (1) hyper-parameter values and complex algorithms that greatly affect model accuracy and (2) operators and periods for temporally aggregating clinical attributes (eg, whether a patient’s weight kept rising in the past year). This process becomes infeasible with limited budgets. Objective This study’s goal is to enable health care researchers to directly use clinical big data, make machine learning feasible with limited budgets and data scientist resources, and realize value from data. Methods This study will allow us to achieve the following: (1) finish developing the new software, Automated Machine Learning (Auto-ML), to automate model selection for machine learning with clinical big data and validate Auto-ML on seven benchmark modeling problems of clinical importance; (2) apply Auto-ML and novel methodology to two new modeling problems crucial for care management allocation and pilot one model with care managers; and (3) perform simulations to estimate the impact of adopting Auto-ML on US patient outcomes. Results We are currently writing Auto-ML’s design document. We intend to finish our study by around the year 2022. Conclusions Auto-ML will generalize to various clinical prediction/classification problems. With minimal help from data scientists, health care researchers can use Auto-ML to quickly build high-quality models. This will boost wider use of machine learning in health care and improve patient outcomes. PMID:28851678

Composite Configuration Interventional Therapy Robot for the Microwave Ablation of Liver Tumors

NASA Astrophysics Data System (ADS)

Cao, Ying-Yu; Xue, Long; Qi, Bo-Jin; Jiang, Li-Pei; Deng, Shuang-Cheng; Liang, Ping; Liu, Jia

2017-11-01

The existing interventional therapy robots for the microwave ablation of liver tumors have a poor clinical applicability with a large volume, low positioning speed and complex automatic navigation control. To solve above problems, a composite configuration interventional therapy robot with passive and active joints is developed. The design of composite configuration reduces the size of the robot under the premise of a wide range of movement, and the robot with composite configuration can realizes rapid positioning with operation safety. The cumulative error of positioning is eliminated and the control complexity is reduced by decoupling active parts. The navigation algorithms for the robot are proposed based on solution of the inverse kinematics and geometric analysis. A simulation clinical test method is designed for the robot, and the functions of the robot and the navigation algorithms are verified by the test method. The mean error of navigation is 1.488 mm and the maximum error is 2.056 mm, and the positioning time for the ablation needle is in 10 s. The experimental results show that the designed robot can meet the clinical requirements for the microwave ablation of liver tumors. The composite configuration is proposed in development of the interventional therapy robot for the microwave ablation of liver tumors, which provides a new idea for the structural design of medical robots.

Podiatry evaluation of a chitosan gelling fibre dressing in diabetic foot ulceration.

PubMed

Walker, Angela

2016-06-23

The purpose of this small evaluation on five patients presenting to community podiatry services in Birmingham with foot ulceration was to explore common problems associated with diabetes and other high-risk conditions and illustrate the clinical effectiveness and experience of using a chitosan absorbent gelling fibre dressing (KytoCel®, Aspen Medical). Each of these case studies bought their individual complex issues and complications that affected the healing process. General wound care involved debridement, if required, dressings, pressure redistribution addressing footwear needs, systemic antibiotics where required, and shared care with the multidisciplinary team (MDT) in secondary care where appropriate.

Clinical applications of cone beam computed tomography in endodontics: A comprehensive review.

PubMed

Cohenca, Nestor; Shemesh, Hagay

2015-09-01

The use of cone beam computed tomography (CBCT) in endodontics has been extensively reported in the literature. Compared with the traditional spiral computed tomography, limited field of view (FOV) CBCT results in a fraction of the effective absorbed dose of radiation. The purpose of this manuscript is to review the application and advantages associated with advanced endodontic problems and complications, while reducing radiation exposure during complex endodontic procedures. The benefits of the added diagnostic information provided by intraoperative CBCT images in select cases justify the risk associated with the limited level of radiation exposure.

The laboratory diagnosis of bacterial vaginosis

PubMed Central

Money, Deborah

2005-01-01

Bacterial vaginosis (BV) is an extremely common health problem for women. In addition to the troublesome symptoms often associated with a disruption in the balance of vaginal flora, BV is associated with adverse gynecological and pregnancy outcomes. Although not technically a sexually transmitted infection, BV is a sexually associated condition. Diagnostic tests include real-time clinical/microbiological diagnosis, and the current gold standard, the standardized evaluation of morphotypes on Gram stain analysis. The inappropriate use of vaginal culture can be misleading. Future developments into molecular-based diagnostics will be important to further understand this complex endogenous flora disruption. PMID:18159532

Observing the sick child: Part 2c. Respiratory auscultation.

PubMed

Aylott, Marion

2007-04-01

Nursing continues to extend its practice base as the acuity of children in general wards often with complex illnesses and treatment increases. There is a need for ongoing development of the physical assessment skills of nurses who care for children and young people in order to facilitate early recognition of clinical problems. Respiratory dysfunction is the common precursor to adverse events. The skill of auscultation adds another dimension that augments the respiratory assessment repertoire of the nurse. This article builds on the palpation skills presented in February issue and provides a practical step-by-step introduction to auscultation.

Cloud Computing for Complex Performance Codes.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Appel, Gordon John; Hadgu, Teklu; Klein, Brandon Thorin

This report describes the use of cloud computing services for running complex public domain performance assessment problems. The work consisted of two phases: Phase 1 was to demonstrate complex codes, on several differently configured servers, could run and compute trivial small scale problems in a commercial cloud infrastructure. Phase 2 focused on proving non-trivial large scale problems could be computed in the commercial cloud environment. The cloud computing effort was successfully applied using codes of interest to the geohydrology and nuclear waste disposal modeling community.

Identifying problems and generating recommendations for enhancing complex systems: applying the abstraction hierarchy framework as an analytical tool.

PubMed

Xu, Wei

2007-12-01

This study adopts J. Rasmussen's (1985) abstraction hierarchy (AH) framework as an analytical tool to identify problems and pinpoint opportunities to enhance complex systems. The process of identifying problems and generating recommendations for complex systems using conventional methods is usually conducted based on incompletely defined work requirements. As the complexity of systems rises, the sheer mass of data generated from these methods becomes unwieldy to manage in a coherent, systematic form for analysis. There is little known work on adopting a broader perspective to fill these gaps. AH was used to analyze an aircraft-automation system in order to further identify breakdowns in pilot-automation interactions. Four steps follow: developing an AH model for the system, mapping the data generated by various methods onto the AH, identifying problems based on the mapped data, and presenting recommendations. The breakdowns lay primarily with automation operations that were more goal directed. Identified root causes include incomplete knowledge content and ineffective knowledge structure in pilots' mental models, lack of effective higher-order functional domain information displayed in the interface, and lack of sufficient automation procedures for pilots to effectively cope with unfamiliar situations. The AH is a valuable analytical tool to systematically identify problems and suggest opportunities for enhancing complex systems. It helps further examine the automation awareness problems and identify improvement areas from a work domain perspective. Applications include the identification of problems and generation of recommendations for complex systems as well as specific recommendations regarding pilot training, flight deck interfaces, and automation procedures.

Transformations of software design and code may lead to reduced errors

NASA Technical Reports Server (NTRS)

Connelly, E. M.

1983-01-01

The capability of programmers and non-programmers to specify problem solutions by developing example-solutions and also for the programmers by writing computer programs was investigated; each method of specification was accomplished at various levels of problem complexity. The level of difficulty of each problem was reflected by the number of steps needed by the user to develop a solution. Machine processing of the user inputs permitted inferences to be developed about the algorithms required to solve a particular problem. The interactive feedback of processing results led users to a more precise definition of the desired solution. Two participant groups (programmers and bookkeepers/accountants) working with three levels of problem complexity and three levels of processor complexity were used. The experimental task employed required specification of a logic for solution of a Navy task force problem.

How can we improve problem solving in undergraduate biology? Applying lessons from 30 years of physics education research.

PubMed

Hoskinson, A-M; Caballero, M D; Knight, J K

2013-06-01

If students are to successfully grapple with authentic, complex biological problems as scientists and citizens, they need practice solving such problems during their undergraduate years. Physics education researchers have investigated student problem solving for the past three decades. Although physics and biology problems differ in structure and content, the instructional purposes align closely: explaining patterns and processes in the natural world and making predictions about physical and biological systems. In this paper, we discuss how research-supported approaches developed by physics education researchers can be adopted by biologists to enhance student problem-solving skills. First, we compare the problems that biology students are typically asked to solve with authentic, complex problems. We then describe the development of research-validated physics curricula emphasizing process skills in problem solving. We show that solving authentic, complex biology problems requires many of the same skills that practicing physicists and biologists use in representing problems, seeking relationships, making predictions, and verifying or checking solutions. We assert that acquiring these skills can help biology students become competent problem solvers. Finally, we propose how biology scholars can apply lessons from physics education in their classrooms and inspire new studies in biology education research.

Machine Learning Approaches in Cardiovascular Imaging.

PubMed

Henglin, Mir; Stein, Gillian; Hushcha, Pavel V; Snoek, Jasper; Wiltschko, Alexander B; Cheng, Susan

2017-10-01

Cardiovascular imaging technologies continue to increase in their capacity to capture and store large quantities of data. Modern computational methods, developed in the field of machine learning, offer new approaches to leveraging the growing volume of imaging data available for analyses. Machine learning methods can now address data-related problems ranging from simple analytic queries of existing measurement data to the more complex challenges involved in analyzing raw images. To date, machine learning has been used in 2 broad and highly interconnected areas: automation of tasks that might otherwise be performed by a human and generation of clinically important new knowledge. Most cardiovascular imaging studies have focused on task-oriented problems, but more studies involving algorithms aimed at generating new clinical insights are emerging. Continued expansion in the size and dimensionality of cardiovascular imaging databases is driving strong interest in applying powerful deep learning methods, in particular, to analyze these data. Overall, the most effective approaches will require an investment in the resources needed to appropriately prepare such large data sets for analyses. Notwithstanding current technical and logistical challenges, machine learning and especially deep learning methods have much to offer and will substantially impact the future practice and science of cardiovascular imaging. © 2017 American Heart Association, Inc.

Gathering, strategizing, motivating and celebrating: the team huddle in a teaching general practice.

PubMed

Walsh, Allyn; Moore, Ainsley; Everson, Jennifer; DeCaire, Katharine

2018-03-01

To understand how implementing a daily team huddle affected the function of a complex interprofessional team including learners. A qualitative descriptive study using semi-structured interviews in focus groups. An academic general practice teaching practice. All members of one interprofessional team, including nurses, general practitioners, junior doctors, and support staff. Focus group interviews using semi-structured guidance were transcribed and the results analysed using qualitative content analysis. Four interrelated themes were identified: communication and knowledge sharing; efficiency of care; relationship and team building; and shared responsibility for team function. The implementation of the daily team huddle was seen by participants to enhance the collaboration within the team and to contribute to work life enjoyment. Participants perceived that problems were anticipated and solved quickly. Clinical updates and information about patients benefited the team including learners. Junior doctors quickly understood the scope of practice of other team members, but some felt reluctant to offer clinical opinions. The implementation of a daily team huddle was viewed as worthwhile by this large interprofessional general practice team. The delivery of patient care was more efficient, knowledge was readily distributed, and problem solving was shared across the team, including junior doctors.

Analogy as a strategy for supporting complex problem solving under uncertainty.

PubMed

Chan, Joel; Paletz, Susannah B F; Schunn, Christian D

2012-11-01

Complex problem solving in naturalistic environments is fraught with uncertainty, which has significant impacts on problem-solving behavior. Thus, theories of human problem solving should include accounts of the cognitive strategies people bring to bear to deal with uncertainty during problem solving. In this article, we present evidence that analogy is one such strategy. Using statistical analyses of the temporal dynamics between analogy and expressed uncertainty in the naturalistic problem-solving conversations among scientists on the Mars Rover Mission, we show that spikes in expressed uncertainty reliably predict analogy use (Study 1) and that expressed uncertainty reduces to baseline levels following analogy use (Study 2). In addition, in Study 3, we show with qualitative analyses that this relationship between uncertainty and analogy is not due to miscommunication-related uncertainty but, rather, is primarily concentrated on substantive problem-solving issues. Finally, we discuss a hypothesis about how analogy might serve as an uncertainty reduction strategy in naturalistic complex problem solving.

[Assessment of competence in pediatric postgraduate education: implementation of a pediatric version of the Mini-Cex].

PubMed

Urman, Gabriela; Folgueral, Silvana; Gasparri, Mercedes; López, Diana; Urman, Jorge; Grosman, Arnoldo; Alves de Lima, Alberto

2011-12-01

Faced with the increased challenge of assessing competences in young doctors, the purpose of the study was to evaluate the implementation of a pediatric version of the Mini-Cex in pediatric trainees as well as the level of satisfaction of teachers and students with the new assessment tool. From July 2007 to August 2009, 54 pediatric trainees were periodically monitored in a variety of clinical settings by 50 teachers. The competences evaluated included medical interviewing, physical examination and counseling skills, humanistic qualities/ professionalism, clinical judgment, organization and overall clinical competence. The feasibility of this study was defined as an average 4 observations per participant, and observations in all clinical rotations. During the study, 388 observations were carried over 54 students (average of 7.18 observations per student); 57% took place in ambulatory settings, 60% were of low complexity and 85% involved healthy children programmed consultations. The ratings for specific competences had little variation; the focus related to the setting. Used in a variety of settings, with different patient problems, the method was well accepted by both students and teachers.

A survey of UK fertility clinics' approach to surrogacy arrangements.

PubMed

Norton, Wendy; Crawshaw, Marilyn; Hudson, Nicky; Culley, Lorraine; Law, Caroline

2015-09-01

This paper draws on the findings of the first survey of surrogacy arrangements in Human Fertilisation and Embryology Authority (HFEA) licensed fertility clinics since 1998. Given the complex social, ethical and legal issues involved, surrogacy continues to raise debate worldwide and fuel calls for increased domestic provision in developed countries. However, little is known about how recent changes have affected HFEA licensed clinics. A 24-item online survey was undertaken between August and October 2013, designed to improve understanding of recent trends and current practices associated with UK-based surrogacy, and consider the implications for future policy and practice in UK and cross-border surrogacy arrangements. The response rate was 51.4%, comprising 54 clinics. Quantitative data were analysed using descriptive statistics, and open-ended qualitative responses analysed for extending understanding. Of the participating clinics, 42.6% offered surrogacy (mostly gestational surrogacy). Heterosexual couples using gestational surrogacy were the largest group currently using services followed by male same-sex couples. Most clinics reported having encountered problems with surrogacy treatments, suggesting barriers still exist to expanding the UK provision of surrogacy arrangements. It is important that professionals are well informed about the legal implications of surrogacy and that clinics have consistent and appropriate operational protocols for surrogacy arrangements. Copyright © 2015 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Problems in sickness certification of patients: a qualitative study on views of 26 physicians in Sweden.

PubMed

von Knorring, Mia; Sundberg, Linda; Löfgren, Anna; Alexanderson, Kristina

2008-01-01

To identify what problems physicians experience in sickness certification of patients. Qualitative analyses of data from six focus-group discussions. Four counties in different regions of Sweden. Twenty-six physicians strategically selected to achieve variation with regard to sex, geographical location, urban/rural area, and type of clinic. The problems involved four areas: society and the social insurance system, the organization of healthcare, the performance of other actors in the system, and the physicians' working situation. In all areas the problems also involved manager issues such as overall leadership, organization of healthcare, and existing incentives and support systems for physicians' handling of patients' sickness certification. Many physicians described feelings of fatigue and a lack of pride in their work with sickness certification tasks, as they believed they contributed to unnecessary sickness absence and to medicalization of patients' non-medical problems. The problems identified have negative consequences both for patients and for the well-being of physicians. Many of the problems seem related to inadequate leadership and management of sickness certification issues. Therefore, they cannot be handled merely by training of physicians, which has so far been the main intervention in this area. They also have to be addressed on manager levels within healthcare. Further research is needed on how physicians cope with the problems identified and on managers' strategies and responsibilities in relation to these problems. If the complexity of the problems is not recognized, there is a risk that inadequate actions will be taken to solve them.

Avoiding bias in medical ethical decision-making. Lessons to be learnt from psychology research.

PubMed

Albisser Schleger, Heidi; Oehninger, Nicole R; Reiter-Theil, Stella

2011-05-01

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making.

The Classical Pathways of Occipital Lobe Epileptic Propagation Revised in the Light of White Matter Dissection

PubMed Central

Latini, Francesco; Hjortberg, Mats; Aldskogius, Håkan; Ryttlefors, Mats

2015-01-01

The clinical evidences of variable epileptic propagation in occipital lobe epilepsy (OLE) have been demonstrated by several studies. However the exact localization of the epileptic focus sometimes represents a problem because of the rapid propagation to frontal, parietal, or temporal regions. Each white matter pathway close to the supposed initial focus can lead the propagation towards a specific direction, explaining the variable semiology of these rare epilepsy syndromes. Some new insights in occipital white matter anatomy are herein described by means of white matter dissection and compared to the classical epileptic patterns, mostly based on the central position of the primary visual cortex. The dissections showed a complex white matter architecture composed by vertical and longitudinal bundles, which are closely interconnected and segregated and are able to support specific high order functions with parallel bidirectional propagation of the electric signal. The same sublobar lesions may hyperactivate different white matter bundles reemphasizing the importance of the ictal semiology as a specific clinical demonstration of the subcortical networks recruited. Merging semiology, white matter anatomy, and electrophysiology may lead us to a better understanding of these complex syndromes and tailored therapeutic options based on individual white matter connectivity. PMID:26063964

Issues in Research on Aging and Suicide

PubMed Central

Van Orden, Kimberly A.; Conwell, Yeates

2016-01-01

Late-life suicide is a complex clinical and public health problem. In this article, some of the key complexities inherent in studying late-life suicide are discussed in the service of promoting high quality late-life suicide prevention science. We discuss the following research issues: the relatively greater lethality of suicidal behavior in later life (compared to younger ages); the lack of data on whether thoughts of death in later life are indicators of suicide risk; the fact that older adults do not tend to seek specialty mental health care, necessitating moving research into primary care clinics and the community; the lack of theory-based research in late-life suicide; the unclear role of cognitive impairment; and the promise of taking a “patient centered” and “participatory research” approach to late-life suicide research efforts. We believe that these perspectives are too often not capitalized upon in research on suicide prevention with older adults and that voice of the older person could contribute much to our understanding of why older adults think about and act on suicidal thoughts, as well as the most acceptable ways to reach and intervene with those at risk. PMID:26179380

[Diagnosis and treatment of metabolic syndrome combined with liver toxicity genesis in contract service officers].

PubMed

Semiserin, V A; Khritinin, D F; Maev, I V; Karakozov, A T; Eremin, M N; Olenicheva, E L

2012-01-01

In this paper is synthesized current and recent data on the problem of metabolic syndrome (MS) in combination with toxic liver injury (CCI). Statistical parameters of the last 15 years, the dynamics of alimentary-constitutional obesity (ABC) in patients from the officers contracted service of Defense Ministry of Russia are reflected. Two-year experience in the application of modern non-invasive methods of diagnosis of liver fibrosis with a reflection of its dynamics on the background of complex treatment of patients with MS in conjunction with the Chamber on the example of 57 patients is shown. Paid great attention to psychological and emotional adjustment of patients with ABC, given the complex survey design and treatment in violation of motivational and behavioral responses. High clinical efficiency of combination drug therapy of MS and CCI, the diagnostic value of modern non-invasive methods of diagnosis of hepatic fibrosis are reliably performed. Technique of elastography significantly improves the liver clinical evaluation of the effectiveness of the therapy, allows for early detect the presence of the initial degree of hepatic fibrosis, choose the optimal treatment regimen and to evaluate the results dynamically.

Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: a clinical comparison study between four clinics.

PubMed

de Graaf, Nastasja M; Cohen-Kettenis, Peggy T; Carmichael, Polly; de Vries, Annelou L C; Dhondt, Karlien; Laridaen, Jolien; Pauli, Dagmar; Ball, Juliane; Steensma, Thomas D

2018-07-01

Adolescents seeking professional help with their gender identity development often present with psychological difficulties. Existing literature on psychological functioning of gender diverse young people is limited and mostly bound to national chart reviews. This study examined the prevalence of psychological functioning and peer relationship problems in adolescents across four European specialist gender services (The Netherlands, Belgium, the UK, and Switzerland), using the Child Behavioural Checklist (CBCL) and the Youth Self-Report (YSR). Differences in psychological functioning and peer relationships were found in gender diverse adolescents across Europe. Overall, emotional and behavioural problems and peer relationship problems were most prevalent in adolescents from the UK, followed by Switzerland and Belgium. The least behavioural and emotional problems and peer relationship problems were reported by adolescents from The Netherlands. Across the four clinics, a similar pattern of gender differences was found. Birth-assigned girls showed more behavioural problems and externalising problems in the clinical range, as reported by their parents. According to self-report, internalising problems in the clinical range were more prevalent in adolescent birth-assigned boys. More research is needed to gain a better understanding of the difference in clinical presentations in gender diverse adolescents and to investigate what contextual factors that may contribute to this.

Solving complex band structure problems with the FEAST eigenvalue algorithm

NASA Astrophysics Data System (ADS)

Laux, S. E.

2012-08-01

With straightforward extension, the FEAST eigenvalue algorithm [Polizzi, Phys. Rev. B 79, 115112 (2009)] is capable of solving the generalized eigenvalue problems representing traveling-wave problems—as exemplified by the complex band-structure problem—even though the matrices involved are complex, non-Hermitian, and singular, and hence outside the originally stated range of applicability of the algorithm. The obtained eigenvalues/eigenvectors, however, contain spurious solutions which must be detected and removed. The efficiency and parallel structure of the original algorithm are unaltered. The complex band structures of Si layers of varying thicknesses and InAs nanowires of varying radii are computed as test problems.

Problems, Solutions, and Strategies Reported by Users of Transcutaneous Electrical Nerve Stimulation for Chronic Musculoskeletal Pain: Qualitative Exploration Using Patient Interviews.

PubMed

Gladwell, Peter William; Badlan, Kathryn; Cramp, Fiona; Palmer, Shea

2016-07-01

Transcutaneous electrical nerve stimulation (TENS) could offer a non-drug form of pain relief, but there is no consensus regarding its effectiveness for chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methods identified significant problems with low treatment fidelity. There is little information available to inform the development of a pragmatic implementation design for a TENS evaluation. The aim of this study was to explore the experiences of patients who were receiving secondary care in a pain clinic and who had expertise in using TENS to manage chronic musculoskeletal pain. These key informants were selected because they had the potential to generate knowledge that could inform research design and clinical practice. A qualitative method using individual semistructured interviews with open questions was selected for its capacity to generate rich data. Semistructured interviews were conducted with 9 patients (6 women, 3 men). Thematic analysis was used as the primary data analysis method, and this analysis was enhanced by a case-level analysis of the context and processes of TENS use of each individual. Data analysis indicated that patients learned to address a range of problems in order to optimize TENS use. Patients may need to personalize the positioning of electrodes and the TENS settings and to readjust them over time. Patients learned to use TENS in a strategic manner, and the outcomes of each strategy varied. The findings indicated that a pragmatic TENS evaluation may need to incorporate a learning phase to allow patients to optimize this complex pattern of TENS usage, and evaluation may need to be sensitive to the outcomes of strategic use. These findings also have implications for clinical practice. © 2016 American Physical Therapy Association.

Managing cognitive impairment in the elderly: conceptual, intervention and methodological issues.

PubMed

Buckwalter, K C; Stolley, J M; Farran, C J

1999-11-11

With the aging of society, the incidence of dementia in the elderly is also increasing, and thus results in increased numbers of individuals with cognitive impairment. Nurses and other researchers have investigated issues concerning the management of cognitive impairment. This article highlights conceptual, intervention and methodological issues associated with this phenomenon. Cognitive change is a multivariate construct that includes alterations in a variety of information processing mechanisms such as problem solving ability, memory, perception, attention and learning, and judgement. Although there is a large body of research, conceptual, intervention and methodological issues remain. Much of the clinical research on cognitive impairment is atheoretical, with this issue only recently being addressed. While many clinical interventions have been proposed, few have been adequately tested. There are also various methodological concerns, such as small sample sizes and limited statistical power; study design issues (experimental vs. non-experimental), and internal and external validity problems. Clearly, additional research designed to intervene with these difficult behaviors is needed. A variety of psychosocial, environmental and physical parameters must be considered in the nursing care of persons with cognitive impairment. Special attention has been given to interventions associated with disruptive behaviors. Interventions are complex and knowledge must be integrated from both the biomedical and behavioral sciences in order to deal effectively with the numerous problems that can arise over a long and changing clinical course. Some researchers and clinicians have suggested that a new culture regarding dementia care is needed, one that focuses on changing attitudes and beliefs about persons with dementia and one that changes how organizations deliver that care. This review identifies key conceptual, intervention and methodological issues and recommends how these issues might be addressed in the future.

Integrated research in natural resources: the key role of problem framing.

Treesearch

Roger N. Clark; George H. Stankey

2006-01-01

Integrated research is about achieving holistic understanding of complex biophysical and social issues and problems. It is driven by the need to improve understanding about such systems and to improve resource management by using the results of integrated research processes.Traditional research tends to fragment complex problems, focusing more on the pieces...

An Exploratory Framework for Handling the Complexity of Mathematical Problem Posing in Small Groups

ERIC Educational Resources Information Center

Kontorovich, Igor; Koichu, Boris; Leikin, Roza; Berman, Avi

2012-01-01

The paper introduces an exploratory framework for handling the complexity of students' mathematical problem posing in small groups. The framework integrates four facets known from past research: task organization, students' knowledge base, problem-posing heuristics and schemes, and group dynamics and interactions. In addition, it contains a new…

The solution of the optimization problem of small energy complexes using linear programming methods

NASA Astrophysics Data System (ADS)

Ivanin, O. A.; Director, L. B.

2016-11-01

Linear programming methods were used for solving the optimization problem of schemes and operation modes of distributed generation energy complexes. Applicability conditions of simplex method, applied to energy complexes, including installations of renewable energy (solar, wind), diesel-generators and energy storage, considered. The analysis of decomposition algorithms for various schemes of energy complexes was made. The results of optimization calculations for energy complexes, operated autonomously and as a part of distribution grid, are presented.

New Insights into Clinical Characteristics of Gilles de la Tourette Syndrome: Findings in 1032 Patients from a Single German Center

PubMed Central

Sambrani, Tanvi; Jakubovski, Ewgeni; Müller-Vahl, Kirsten R.

2016-01-01

Background: Gilles de la Tourette syndrome (TS) is a complex neuropsychiatric disorder defined by the presence of motor and phonic tics, but often associated with psychiatric comorbidities. The main objective of this study was to explore the clinical presentation and comorbidities of TS. Method: We analyzed clinical data obtained from a large sample (n = 1032; 529 children and 503 adults) of patients with tic disorders from one single German TS center assessed by one investigator. Data was collected with the help of an expert-reviewed semi-structured interview, designed to assess tic severity and certain comorbidities. Group comparisons were carried out via independent sample t-tests and chi-square tests. Results: The main findings of the study are: (1) tic severity is associated with the presence of premonitory urges (PU), copro-, echo-, and paliphenomena and the number of comorbidities, but not age at tic onset; it is higher in patients with comorbid obsessive-compulsive disorder (OCD) than in patients with comorbid attention deficit/hyperactivity disorder (ADHD). (2) PU were found to be highly associated with “not just right experiences” and to emerge much earlier than previously thought alongside with the ability to suppress tics (PU in >60% and suppressibility in >75% at age 8–10 years). (3) Self-injurious behavior (SIB) is highly associated with complex motor tics and coprophenomena, but not with OCD/obsessive-compulsive behavior (OCB). While comorbid ADHD is associated with a lower ability to suppress tics, comorbid depression is associated with sleeping problems. Discussion: Our results demonstrate that tic severity is not influenced by age at onset. From our data, it is suggested that PU represent a specific type of “not just right experience” that is not a prerequisite for tic suppression. Comorbid ADHD reduces patients' ability of successful tic suppression. Our data suggest that SIB belongs to the coprophenomena spectrum and hence should be conceptualized as a complex tic rather than a compulsion. Finally, this study strongly supports the hypothesis that TS+OCD is a more severe form of TS and that comorbid OCD/OCB, depression, and anxiety belong to the TS spectrum, while ADHD should be better conceptualized as a separate problem. PMID:27672357

Mobile technology supporting trainee doctors’ workplace learning and patient care: an evaluation

PubMed Central

2013-01-01

Background The amount of information needed by doctors has exploded. The nature of knowledge (explicit and tacit) and processes of knowledge acquisition and participation are complex. Aiming to assist workplace learning, Wales Deanery funded “iDoc”, a project offering trainee doctors a Smartphone library of medical textbooks. Methods Data on trainee doctors’ (Foundation Year 2) workplace information seeking practice was collected by questionnaire in 2011 (n = 260). iDoc baseline questionnaires (n = 193) collected data on Smartphone usage alongside other workplace information sources. Case reports (n = 117) detail specific instances of Smartphone use. Results Most frequently (daily) used information sources in the workplace: senior medical staff (80% F2 survey; 79% iDoc baseline); peers (70%; 58%); and other medical/nursing team staff (53% both datasets). Smartphones were used more frequently by males (p < 0.01). Foundation Year 1 (newly qualified) was judged the most useful time to have a Smartphone library because of increased responsibility and lack of knowledge/experience. Preferred information source varied by question type: hard copy texts for information-based questions; varied resources for skills queries; and seniors for more complex problems. Case reports showed mobile technology used for simple (information-based), complex (problem-based) clinical questions and clinical procedures (skills-based scenarios). From thematic analysis, the Smartphone library assisted: teaching and learning from observation; transition from medical student to new doctor; trainee doctors’ discussions with seniors; independent practice; patient care; and this ‘just-in-time’ access to reliable information supported confident and efficient decision-making. Conclusion A variety of information sources are used regularly in the workplace. Colleagues are used daily but seniors are not always available. During transitions, constant access to the electronic library was valued. It helped prepare trainee doctors for discussions with their seniors, assisting the interchange between explicit and tacit knowledge. By supporting accurate prescribing and treatment planning, the electronic library contributed to enhanced patient care. Trainees were more rapidly able to medicate patients to reduce pain and more quickly call for specific assessments. However, clinical decision-making often requires dialogue: what Smartphone technology can do is augment, not replace, discussion with their colleagues in the community of practice. PMID:23336964

Making Good Decisions in Healthcare with Multi-Criteria Decision Analysis: The Use, Current Research and Future Development of MCDA.

PubMed

Mühlbacher, Axel C; Kaczynski, Anika

2016-02-01

Healthcare decision making is usually characterized by a low degree of transparency. The demand for transparent decision processes can be fulfilled only when assessment, appraisal and decisions about health technologies are performed under a systematic construct of benefit assessment. The benefit of an intervention is often multidimensional and, thus, must be represented by several decision criteria. Complex decision problems require an assessment and appraisal of various criteria; therefore, a decision process that systematically identifies the best available alternative and enables an optimal and transparent decision is needed. For that reason, decision criteria must be weighted and goal achievement must be scored for all alternatives. Methods of multi-criteria decision analysis (MCDA) are available to analyse and appraise multiple clinical endpoints and structure complex decision problems in healthcare decision making. By means of MCDA, value judgments, priorities and preferences of patients, insurees and experts can be integrated systematically and transparently into the decision-making process. This article describes the MCDA framework and identifies potential areas where MCDA can be of use (e.g. approval, guidelines and reimbursement/pricing of health technologies). A literature search was performed to identify current research in healthcare. The results showed that healthcare decision making is addressing the problem of multiple decision criteria and is focusing on the future development and use of techniques to weight and score different decision criteria. This article emphasizes the use and future benefit of MCDA.

Bridge to the future: nontraditional clinical settings, concepts and issues.

PubMed

Faller, H S; Dowell, M A; Jackson, M A

1995-11-01

Healthcare restructuring in the wake of healthcare reform places greater emphasis on primary healthcare. Clinical education in acute care settings and existing community health agencies are not compatible with teaching basic concepts, principles and skills fundamental to nursing. Problems of clients in acute care settings are too complex and clients in the community are often too dispersed for necessary faculty support and supervision of beginning nursing students. Nontraditional learning settings offer the baccalaureate student the opportunity to practice fundamental skills of care and address professional skills of negotiation, assertiveness, organization, collaboration and leadership. An overview of faculty designed clinical learning experiences in nontraditional sites such as McDonald's restaurants, inner city churches, YWCA's, the campus community and homes are presented. The legal, ethical and academic issues associated with nontraditional learning settings are discussed in relation to individual empowerment, decision making and evaluation. Implications for the future address the role of the students and faculty as they interact with the community in which they live and practice.

Unexplained high thyroid stimulating hormone: a "BIG" problem.

PubMed

Mendoza, Heidi; Connacher, Alan; Srivastava, Rajeev

2009-01-01

Macro-hormones and macro-enzymes are high molecular weight conjugates of hormones or enzymes, respectively, often with immunoglobulins. These are referred to as macromolecular complexes, and may cause artefactually elevated biochemical tests results. Macro enzymes of the most commonly measured serum enzymes have been identified and are recognised as a source of elevated measurements that may cause diagnostic confusion; macro-creatine kinase and macro-amylase are the two better known macro-enzymes in clinical practice. Literature on macro-hormones is largely restricted to macro-prolactin. We present a case of a clinically euthyroid patient, who had persistently elevated thyroid stimulating hormone (TSH) but free thyroxine within the reference limits. She underwent repeated thyroid investigations and thyroid hormone interference studies, until macro-TSH was identified as the most likely cause of unexplained elevated TSH. Following the identification and characterisation of this biochemical abnormality, she is no longer subject to repeated blood tests for assessment of thyroid function; the patient currently remains clinically euthyroid.

Challenges in reducing dengue burden; diagnostics, control measures and vaccines.

PubMed

Lam, Sai Kit

2013-09-01

Dengue is a major public health concern worldwide, with the number of infections increasing globally. The illness imposes the greatest economic and human burden on developing countries that have limited resources to deal with the scale of the problem. No cure for dengue exists; treatment is limited to rehydration therapy, and with vector control strategies proving to be relatively ineffective, a vaccine is an urgent priority. Despite the numerous challenges encountered in the development of a dengue vaccine, several vaccine candidates have shown promise in clinical development and it is believed that a vaccination program would be at least as cost-effective as current vector control programs. The lead candidate vaccine is a tetravalent, live attenuated, recombinant vaccine, which is currently in Phase III clinical trials. Vaccine introduction is a complex process that requires consideration and is discussed here. This review discusses the epidemiology, burden and pathogenesis of dengue, as well as the vaccine candidates currently in clinical development.

Integrated Blood Barcode Chips

PubMed Central

Fan, Rong; Vermesh, Ophir; Srivastava, Alok; Yen, Brian K.H.; Qin, Lidong; Ahmad, Habib; Kwong, Gabriel A.; Liu, Chao-Chao; Gould, Juliane; Hood, Leroy; Heath, James R.

2008-01-01

Blood comprises the largest version of the human proteome1. Changes of plasma protein profiles can reflect physiological or pathological conditions associated with many human diseases, making blood the most important fluid for clinical diagnostics2-4. Nevertheless, only a handful of plasma proteins are utilized in routine clinical tests. This is due to a host of reasons, including the intrinsic complexity of the plasma proteome1, the heterogeneity of human diseases and the fast kinetics associated with protein degradation in sampled blood5. Simple technologies that can sensitively sample large numbers of proteins over broad concentration ranges, from small amounts of blood, and within minutes of sample collection, would assist in solving these problems. Herein, we report on an integrated microfluidic system, called the Integrated Blood Barcode Chip (IBBC). It enables on-chip blood separation and the rapid measurement of a panel of plasma proteins from small quantities of blood samples including a fingerprick of whole blood. This platform holds potential for inexpensive, non-invasive, and informative clinical diagnoses, particularly, for point-of-care. PMID:19029914

Fluorescence fluctuation spectroscopy for clinical applications

NASA Astrophysics Data System (ADS)

Olson, Eben

Fluorescence correlation spectroscopy (FCS) and the related techniques of brightness analysis have become standard tools in biological and biophysical research. By analyzing the statistics of fluorescence emitted from a restricted volume, a number of parameters including concentrations, diffusion coefficients and chemical reaction rates can be determined. The single-molecule sensitivity, spectral selectivity, small sample volume and non-perturbative measurement mechanism of FCS make it an excellent technique for the study of molecular interactions. However, its adoption outside of the research laboratory has been limited. Potential reasons for this include the cost and complexity of the required apparatus. In this work, the application of fluorescence fluctuation analysis to several clinical problems is considered. Optical designs for FCS instruments which reduce the cost and increase alignment tolerance are presented. Brightness analysis of heterogenous systems, with application to the characterization of protein aggregates and multimer distributions, is considered. Methods for FCS-based assays of two clinically relevant proteins, von Willebrand factor and haptoglobin, are presented as well.

Bigger Data, Bigger Problems.

PubMed

Slobogean, Gerard P; Giannoudis, Peter V; Frihagen, Frede; Forte, Mary L; Morshed, Saam; Bhandari, Mohit

2015-12-01

Clinical studies frequently lack the ability to reliably answer their research questions because of inadequate sample sizes. Underpowered studies are subject to multiple sources of bias, may not represent the larger population, and are regularly unable to detect differences between treatment groups. Most importantly, an underpowered study can lead to incorrect conclusions. Big data can be used to address many of these concerns, enabling researchers to answer questions with increased certainty and less likelihood of bias. Big datasets, such as The National Hip Fracture Database in the United Kingdom and the Swedish Hip Arthroplasty Registry, collect valuable clinical information that can be used by researchers to guide patient care and inform policy makers, chief executives, commissioners, and clinical staff. The range of research questions that can be examined is directly related to the quality and complexity of the data, which is positively associated with the cost of the data. However, technological advancements have unlocked new possibilities for efficient data capture and widespread opportunities to merge massive datasets, particularly in the setting of national registries and administrative data.

A FMEA clinical laboratory case study: how to make problems and improvements measurable.

PubMed

Capunzo, Mario; Cavallo, Pierpaolo; Boccia, Giovanni; Brunetti, Luigi; Pizzuti, Sante

2004-01-01

The authors have experimented the application of the Failure Mode and Effect Analysis (FMEA) technique in a clinical laboratory. FMEA technique allows: a) to evaluate and measure the hazards of a process malfunction, b) to decide where to execute improvement actions, and c) to measure the outcome of those actions. A small sample of analytes has been studied: there have been determined the causes of the possible malfunctions of the analytical process, calculating the risk probability index (RPI), with a value between 1 and 1,000. Only for the cases of RPI > 400, improvement actions have been implemented that allowed a reduction of RPI values between 25% to 70% with a costs increment of < 1%. FMEA technique can be applied to the processes of a clinical laboratory, even if of small dimensions, and offers a high potential of improvement. Nevertheless, such activity needs a thorough planning because it is complex, even if the laboratory already operates an ISO 9000 Quality Management System.

A Dimensional Bus model for integrating clinical and research data.

PubMed

Wade, Ted D; Hum, Richard C; Murphy, James R

2011-12-01

Many clinical research data integration platforms rely on the Entity-Attribute-Value model because of its flexibility, even though it presents problems in query formulation and execution time. The authors sought more balance in these traits. Borrowing concepts from Entity-Attribute-Value and from enterprise data warehousing, the authors designed an alternative called the Dimensional Bus model and used it to integrate electronic medical record, sponsored study, and biorepository data. Each type of observational collection has its own table, and the structure of these tables varies to suit the source data. The observational tables are linked to the Bus, which holds provenance information and links to various classificatory dimensions that amplify the meaning of the data or facilitate its query and exposure management. The authors implemented a Bus-based clinical research data repository with a query system that flexibly manages data access and confidentiality, facilitates catalog search, and readily formulates and compiles complex queries. The design provides a workable way to manage and query mixed schemas in a data warehouse.

Will there be room for the teaching of internal medicine in a university hospital?

PubMed

Junod, Alain F

2002-01-12

To answer the question addressed, two working groups, one made of the staff of a University clinic, the other one composed of practising general internists, have discussed the assets and weaknesses of a University service of Internal Medicine for postgraduate training. The groups agreed on a number of points: patients' characteristics (complexity and co-morbidities), quality of teaching, method acquisition for clinical reasoning, as well as absence of exposure to ambulatory patients and of follow-up. The groups differed in their views related to the lack of training in psychiatry and psychosocial problems or to hospital dysfunctions. Opening of internal medicine to primary care appears to be necessary at the same time as individual qualities among the senior staff are to be developed, such as critical analysis and self-questioning.

THE PROCESS OF Leishmania INFECTION - DISEASE AND NEW PERSPECTIVES OF PALEOPARASITOLOGY

PubMed Central

NOVO, Shênia Patrícia Corrêa; LELES, Daniela; BIANUCCI, Raffaella; ARAUJO, Adauto

2016-01-01

Species of the genus Leishmania (Kinetoplastida, Trypanosomatidae) are causative agents of leishmaniasis, a complex disease with variable clinical spectrum and epidemiological diversity, constituting, in some countries, a serious public health problem. The origin and evolution of leishmaniasis has been under discussion regarding some clinical and parasitological aspects. After the introduction of paleoparasitology, molecular methods and immunodiagnostic techniques have been applied allowing the recovery of parasite remains, as well as the diagnosis of past infections in humans and other hosts. The dating of archaeological samples has allowed the parasitological analysis in time and space. This manuscript presents the state of the art of leishmaniasis and prospects related to paleoparasitology studies and their contribution to the evolutionary and phylogenetic clarification of parasites belonging to the genus Leishmania, and the leishmaniasis caused by them. PMID:27253747

Split gender identity: problem or solution? Proposed parameters for addressing the gender dysphoric patient.

PubMed

Osborne, Cynthia; Wise, Thomas N

2002-01-01

Working with the gender dysphoric patient is complex because of the various clinical issues that arise. One issue that has not been addressed in the psychiatric literature is whether to address the patient with the biologically congruent pronoun or name or with the patient's preferred-gender pronoun or cross-gender name. This article presents clinical examples that allow a template to be developed for pronoun use in working with such patients. Whether the clinician uses biologically congruent names and pronouns may depend upon the patient's progress in adopting the cross gender role as well whether family or friends either know or accept such changes. In certain situations, such as meetings with family members, the therapist may address the patient with gender congruent names; whereas on other occasions use cross-gender pronouns or names.

Reproductive Life Planning: Raising the Questions.

PubMed

Morse, Jessica E; Moos, Merry-K

2018-04-01

Introduction Unintended pregnancy has been a concerning public health problem for decades. As we begin to understand the complexities of pregnancy intention and how women experience these pregnancies, reproductive life planning offers a paradigm shift. Methods Reproductive life planning is a patient-centered approach that places a patient's reproductive preferences-whether concrete or ambivalent-at the forefront of her clinical care. Results This process grants women and men the opportunity to consider how reproduction fits within the context of their broader lives. Within a clinical encounter, reproductive life planning allows counseling and care to be tailored to patient preferences. Discussion Although there is great potential for positive public health impacts in unintended pregnancy, contraceptive use and improved preconception health, the true benefit lies within reinforcing reproductive empowerment. Despite recommendations for universal adoption, many questions remain regarding implementation, equity and outcomes.

Numerical FEM modeling in dental implantology

NASA Astrophysics Data System (ADS)

Roateşi, Iulia; Roateşi, Simona

2016-06-01

This paper is devoted to a numerical approach of the stress and displacement calculation of a system made up of dental implant, ceramic crown and surrounding bone. This is the simulation of a clinical situation involving both biological - the bone tissue, and non-biological - the implant and the crown, materials. On the other hand this problem deals with quite fine technical structure details - the threads, tapers, etc with a great impact in masticatory force transmission. Modeling the contact between the implant and the bone tissue is important to a proper bone-implant interface model and implant design. The authors proposed a three-dimensional numerical model to assess the biomechanical behaviour of this complex structure in order to evaluate its stability by determining the risk zones. A comparison between this numerical analysis and clinical cases is performed and a good agreement is obtained.

Biomechanics of Reverse Shoulder Arthroplasty: 
Current Concepts.

PubMed

Lorenzetti, Adam J; Stone, Geoffrey P; Simon, Peter; Frankle, Mark A

2016-01-01

The evolution of reverse shoulder arthroplasty has provided surgeons with new solutions for many complex shoulder problems. A primary goal of orthopaedics is the restoration or re-creation of functional anatomy to reduce pain and improve function, which can be accomplished by either repairing injured structures or replacing them as anatomically as possible. If reconstructible tissue is lacking or not available, which is seen in patients who have complex shoulder conditions such as an irreparable rotator cuff-deficient shoulder, cuff tear arthropathy, or severe glenoid bone loss, substantial problems may arise. Historically, hemiarthroplasty or glenoid grafting with total shoulder arthroplasty yielded inconsistent and unsatisfactory results. Underlying pathologies in patients who have an irreparable rotator cuff-deficient shoulder, cuff tear arthropathy, or severe glenoid bone loss can considerably alter the mechanical function of the shoulder and create treatment dilemmas that are difficult to overcome. A better biomechanical understanding of these pathologic adaptations has improved treatment options. In the past three decades, reverse total shoulder arthroplasty was developed to treat these complex shoulder conditions not by specifically re-creating the anatomy but by using the remaining functional tissue to improve shoulder balance. Reverse total shoulder arthroplasty has achieved reliable improvements in both pain and function. Initial implant designs lacked scientific evidence to support the design rationale, and many implants failed because surgeons did not completely understand the forces involved or the pathology being treated. Implant function and clinical results will continue to improve as surgeons' biomechanical understanding of shoulder disease and reverse shoulder arthroplasty implants increases.

Evidence-based medicine: is it a bridge too far?

PubMed

Fernandez, Ana; Sturmberg, Joachim; Lukersmith, Sue; Madden, Rosamond; Torkfar, Ghazal; Colagiuri, Ruth; Salvador-Carulla, Luis

2015-11-06

This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context. EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

An 'Honest Broker' mechanism to maintain privacy for patient care and academic medical research.

PubMed

Boyd, Andrew D; Hosner, Charlie; Hunscher, Dale A; Athey, Brian D; Clauw, Daniel J; Green, Lee A

2007-01-01

From the Hippocratic Oath to the World Medical Association's Declaration of Geneva, physicians have sworn to protect patients' privacy. However, as systems move to more integrated architectures, protecting this medical data becomes more of a challenge. The increase in complexity of IT environments, the aggregation of data, and the desire of other entities to access this data, often 24 h/day x 7 day/week x 365 day/year, is putting serious strains on our ability to maintain its security. This problem cuts across all electronic record sources from patient care records to academic medical research records. In order to address this issue, we are rethinking the way we store, transmit, process, access, and federate patient data from clinical and research applications. Our groups at the University of Michigan are developing a system called the "Honest Broker" to help manage this problem. The Honest Broker will offload the burden of housing identifiable data elements of protected health information (PHI) (e.g., name and address) as well as manage data transfer between clinical and research systems. Lab results and other non-identifiable data will be stored in separate systems with either a research study ID or clinical ID number. This two-component architecture increases the burden on attackers who now need to compromise two systems, one of which is seriously hardened, in order to match health data with a patient's actual identity. While no security system is truly intrusion-proof, this architecture provides a high security choke point reducing the likelihood of a breach. By redesigning the method of integrating clinical care and research, we have enabled projects that would be cost prohibitive to conduct otherwise. The scalability of this mechanism is dependant on nature of the heterogenous nature of the clinical systems serving patients.

Hunter disease eClinic: interactive, computer-assisted, problem-based approach to independent learning about a rare genetic disease

PubMed Central

2010-01-01

Background Computer-based teaching (CBT) is a well-known educational device, but it has never been applied systematically to the teaching of a complex, rare, genetic disease, such as Hunter disease (MPS II). Aim To develop interactive teaching software functioning as a virtual clinic for the management of MPS II. Implementation and Results The Hunter disease eClinic, a self-training, user-friendly educational software program, available at the Lysosomal Storage Research Group (http://www.lysosomalstorageresearch.ca), was developed using the Adobe Flash multimedia platform. It was designed to function both to provide a realistic, interactive virtual clinic and instantaneous access to supporting literature on Hunter disease. The Hunter disease eClinic consists of an eBook and an eClinic. The eClinic is the interactive virtual clinic component of the software. Within an environment resembling a real clinic, the trainee is instructed to perform a medical history, to examine the patient, and to order appropriate investigation. The program provides clinical data derived from the management of actual patients with Hunter disease. The eBook provides instantaneous, electronic access to a vast collection of reference information to provide detailed background clinical and basic science, including relevant biochemistry, physiology, and genetics. In the eClinic, the trainee is presented with quizzes designed to provide immediate feedback on both trainee effectiveness and efficiency. User feedback on the merits of the program was collected at several seminars and formal clinical rounds at several medical centres, primarily in Canada. In addition, online usage statistics were documented for a 2-year period. Feedback was consistently positive and confirmed the practical benefit of the program. The online English-language version is accessed daily by users from all over the world; a Japanese translation of the program is also available. Conclusions The Hunter disease eClinic employs a CBT model providing the trainee with realistic clinical problems, coupled with comprehensive basic and clinical reference information by instantaneous access to an electronic textbook, the eBook. The program was rated highly by attendees at national and international presentations. It provides a potential model for use as an educational approach to other rare genetic diseases. PMID:20973983

Deformable segmentation via sparse representation and dictionary learning.

PubMed

Zhang, Shaoting; Zhan, Yiqiang; Metaxas, Dimitris N

2012-10-01

"Shape" and "appearance", the two pillars of a deformable model, complement each other in object segmentation. In many medical imaging applications, while the low-level appearance information is weak or mis-leading, shape priors play a more important role to guide a correct segmentation, thanks to the strong shape characteristics of biological structures. Recently a novel shape prior modeling method has been proposed based on sparse learning theory. Instead of learning a generative shape model, shape priors are incorporated on-the-fly through the sparse shape composition (SSC). SSC is robust to non-Gaussian errors and still preserves individual shape characteristics even when such characteristics is not statistically significant. Although it seems straightforward to incorporate SSC into a deformable segmentation framework as shape priors, the large-scale sparse optimization of SSC has low runtime efficiency, which cannot satisfy clinical requirements. In this paper, we design two strategies to decrease the computational complexity of SSC, making a robust, accurate and efficient deformable segmentation system. (1) When the shape repository contains a large number of instances, which is often the case in 2D problems, K-SVD is used to learn a more compact but still informative shape dictionary. (2) If the derived shape instance has a large number of vertices, which often appears in 3D problems, an affinity propagation method is used to partition the surface into small sub-regions, on which the sparse shape composition is performed locally. Both strategies dramatically decrease the scale of the sparse optimization problem and hence speed up the algorithm. Our method is applied on a diverse set of biomedical image analysis problems. Compared to the original SSC, these two newly-proposed modules not only significant reduce the computational complexity, but also improve the overall accuracy. Copyright © 2012 Elsevier B.V. All rights reserved.

Fluctuating residual limb volume accommodated with an adjustable, modular socket design: A novel case report.

PubMed

Mitton, Kay; Kulkarni, Jai; Dunn, Kenneth William; Ung, Anthony Hoang

2017-10-01

This novel case report describes the problems of prescribing a prosthetic socket in a left transfemoral amputee secondary to chronic patellofemoral instability compounded by complex regional pain syndrome. Case Description and Methods: Following the amputation, complex regional pain syndrome symptoms recurred in the residual limb, presenting mainly with oedema. Due to extreme daily volume fluctuations of the residual limb, a conventional, laminated thermoplastic socket fitting was not feasible. Findings and Outcomes: An adjustable, modular socket design was trialled. The residual limb volume fluctuations were accommodated within the socket. Amputee rehabilitation could be continued, and the rehabilitation goals were achieved. The patient was able to wear the prosthesis for 8 h daily and to walk unaided indoors and outdoors. An adjustable, modular socket design accommodated the daily residual limb volume fluctuations and provided a successful outcome in this case. It demonstrates the complexities of socket fitting and design with volume fluctuations. Clinical relevance Ongoing complex regional pain syndrome symptoms within the residual limb can lead to fitting difficulties in a conventional, laminated thermoplastic socket due to volume fluctuations. An adjustable, modular socket design can accommodate this and provide a successful outcome.

Anticoagulant treatment of medical patients with complex clinical conditions.

PubMed

Ruiz-Ruiz, F; Medrano, F J; Santos-Lozano, J M; Rodríguez-Torres, P; Navarro-Puerto, A; Calderón, E J

2018-06-12

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic. Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.

A case-based reasoning tool for breast cancer knowledge management with data mining concepts and techniques

NASA Astrophysics Data System (ADS)

Demigha, Souâd.

2016-03-01

The paper presents a Case-Based Reasoning Tool for Breast Cancer Knowledge Management to improve breast cancer screening. To develop this tool, we combine both concepts and techniques of Case-Based Reasoning (CBR) and Data Mining (DM). Physicians and radiologists ground their diagnosis on their expertise (past experience) based on clinical cases. Case-Based Reasoning is the process of solving new problems based on the solutions of similar past problems and structured as cases. CBR is suitable for medical use. On the other hand, existing traditional hospital information systems (HIS), Radiological Information Systems (RIS) and Picture Archiving Information Systems (PACS) don't allow managing efficiently medical information because of its complexity and heterogeneity. Data Mining is the process of mining information from a data set and transform it into an understandable structure for further use. Combining CBR to Data Mining techniques will facilitate diagnosis and decision-making of medical experts.

Skin and psyche--from the surface to the depth of the inner world.

PubMed

Beltraminelli, Helmut; Itin, Peter

2008-01-01

About 30% of dermatology patients have signs or symptoms of psychological problems. Dermatologists should be familiar with the basics needed to identify, advise and treat these patients. Because of the complex interaction between skin and psyche, it is difficult to distinguish whether the primary problem is the skin or the psyche. Sometimes the clinical picture is a consequence of interactions between them and other factors. The interactions between skin and psyche are well known in history, art and literature--perhaps better known today because the marked emphasis on such images in our modern multimedia society. Aging is increasingly perceived as an illness and not as a physiological process. Through globalization, many different cultural approaches to the skin have entered in our daily life and influence our communication. This article considers the most important dermatoses which often show primary or secondary interaction with the psyche.

Bourdieu at the bedside: briefing parents in a pediatric hospital.

PubMed

LeGrow, Karen; Hodnett, Ellen; Stremler, Robyn; McKeever, Patricia; Cohen, Eyal

2014-12-01

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting. © 2014 John Wiley & Sons Ltd.

The limitations of 'evidence-based' public health.

PubMed

Kemm, John

2006-06-01

This paper examines how the concept of the 'evidence-based' approach has transferred from clinical medicine to public health and has been applied to health promotion and policy making. In policy making evidence has always been interpreted broadly to cover all types of reasoned enquiry and after some debate the same is now true for health promotion. Taking communities rather than individuals as the unit of intervention and the importance of context means that frequently randomized controlled trials are not appropriate for study of public health interventions. Further, the notion of a 'best solution' ignores the complexity of the decision making process. Evidence 'enlightens' policy makers shaping how policy problems are framed rather than providing the answer to any particular problem. There are lessons from the way that evidence-based policy is being applied in public health that could usefully be taken back into medicine.

Thinking and working relationally: interviewing and constructing hypotheses to create compassionate understanding.

PubMed

Sheinberg, Marcia; Brewster, Mary Kim

2014-12-01

In the initial interviews of family therapy sessions, the therapist faces the challenge of obtaining and organizing the information that is most relevant toward understanding the essential concerns that families and couples bring to therapy. This article describes the process of clinical interviewing and case conceptualization used in training family therapists at the Ackerman Institute for the Family. This approach helps the therapist bring forward, and organize, specific information into relational hypotheses, or systemic-relational conceptualizations, that allow both family members and the therapist to understand presenting problems within their relational contexts. While always provisional, relational hypotheses help anchor the therapist in a systemic-relational frame and provide a conceptual through-line to guide the ongoing work of the therapy. The process of interviewing and the construction of clear and complex conceptualizations of presenting problems are illustrated through case examples. © 2014 Family Process Institute.

A Model for Developing Improvements to Critical Thinking Skills across the Community College Curriculum

ERIC Educational Resources Information Center

McGarrity, DeShawn N.

2013-01-01

Society is faced with more complex problems than in the past because of rapid advancements in technology. These complex problems require multi-dimensional problem-solving abilities that are consistent with higher-order thinking skills. Bok (2006) posits that over 90% of U.S. faculty members consider critical thinking skills as essential for…

A Real-Life Case Study of Audit Interactions--Resolving Messy, Complex Problems

ERIC Educational Resources Information Center

Beattie, Vivien; Fearnley, Stella; Hines, Tony

2012-01-01

Real-life accounting and auditing problems are often complex and messy, requiring the synthesis of technical knowledge in addition to the application of generic skills. To help students acquire the necessary skills to deal with these problems effectively, educators have called for the use of case-based methods. Cases based on real situations (such…

Student Learning of Complex Earth Systems: A Model to Guide Development of Student Expertise in Problem-Solving

ERIC Educational Resources Information Center

Holder, Lauren N.; Scherer, Hannah H.; Herbert, Bruce E.

2017-01-01

Engaging students in problem-solving concerning environmental issues in near-surface complex Earth systems involves developing student conceptualization of the Earth as a system and applying that scientific knowledge to the problems using practices that model those used by professionals. In this article, we review geoscience education research…

Utilizing a Sense of Community Theory in Order to Optimize Interagency Response to Complex Contingencies

DTIC Science & Technology

2010-06-01

of Not at all Somewhat Mostly Completely membership such as clothes , signs, art, architecture, logos , landmarks, and flags that people can...on a ?whole of nation? approach to solving complex problems. Psychological sense of community (PSOC) theory provides the link that explains how an...States during complex contingency operations depends on a “whole of nation” approach to solving complex problems. Psychological sense of community

Solution of a Complex Least Squares Problem with Constrained Phase.

PubMed

Bydder, Mark

2010-12-30

The least squares solution of a complex linear equation is in general a complex vector with independent real and imaginary parts. In certain applications in magnetic resonance imaging, a solution is desired such that each element has the same phase. A direct method for obtaining the least squares solution to the phase constrained problem is described.

Factors Affecting Police Officers' Acceptance of GIS Technologies: A Study of the Turkish National Police

ERIC Educational Resources Information Center

Cakar, Bekir

2011-01-01

The situations and problems that police officers face are more complex in today's society, due in part to the increase of technology and growing complexity of globalization. Accordingly, to solve these problems and deal with the complexities, law enforcement organizations develop and apply new techniques and methods such as geographic information…

Anodal Transcranial Direct Current Stimulation of the Prefrontal Cortex Enhances Complex Verbal Associative Thought

ERIC Educational Resources Information Center

Cerruti, Carlo; Schlaug, Gottfried

2009-01-01

The remote associates test (RAT) is a complex verbal task with associations to both creative thought and general intelligence. RAT problems require not only lateral associations and the internal production of many words but a convergent focus on a single answer. Complex problem-solving of this sort may thus require both substantial verbal…

[Study on building index system of risk assessment of post-marketing Chinese patent medicine based on AHP-fuzzy neural network].

PubMed

Li, Yuanyuan; Xie, Yanming; Fu, Yingkun

2011-10-01

Currently massive researches have been launched about the safety, efficiency and economy of post-marketing Chinese patent medicine (CPM) proprietary Chinese medicine, but it was lack of a comprehensive interpretation. Establishing the risk evaluation index system and risk assessment model of CPM is the key to solve drug safety problems and protect people's health. The clinical risk factors of CPM exist similarities with the Western medicine, can draw lessons from foreign experience, but also have itself multi-factor multivariate multi-level complex features. Drug safety risk assessment for the uncertainty and complexity, using analytic hierarchy process (AHP) to empower the index weights, AHP-based fuzzy neural network to build post-marketing CPM risk evaluation index system and risk assessment model and constantly improving the application of traditional Chinese medicine characteristic is accord with the road and feasible beneficial exploration.

Has Neo-Darwinism failed clinical medicine: does systems biology have to?

PubMed

Joyner, Michael J

2015-01-01

In this essay I argue that Neo-Darwinism ultimately led to an oversimplified genotype equals phenotype view of human disease. This view has been called into question by the unexpected results of the Human Genome Project which has painted a far more complex picture of the genetic features of human disease than was anticipated. Cell centric Systems Biology is now attempting to reconcile this complexity. However, it too is limited because most common chronic diseases have systemic components not predicted by their intracellular responses alone. In this context, congestive heart failure is a classic example of this general problem and I discuss it as a systemic disease vs. one solely related to dysfunctional cardiomyocytes. I close by arguing that a physiological perspective is essential to reconcile reductionism with what is required to understand and treat disease. Copyright © 2014 Elsevier Ltd. All rights reserved.

Multidisciplinary Approach in the Management of a Complex Case: Implant-Prosthetic Rehabilitation of a Periodontal Smoking Patient with Partial Edentulism, Malocclusion, and Aesthetic Diseases

PubMed Central

Di Francesco, Fabrizio; De Marco, Gennaro; Scognamiglio, Fabio; Aruta, Valeria; Itro, Angelo

2017-01-01

Complex periprosthetic cases are considered as challenges by clinicians. Clinical and radiographic parameters should be considered separately to make the right choice between an endodontically or periodontally compromised treated tooth and implant. Therefore, in order to decide whether the tooth is safe or not, data that have to be collected are specific parameters of both the patient and the clinician. In addition, the presence of periodontal, prosthetic, and orthodontic diseases requires patients to be set in multidisciplinary approach. The aim of this case report is to describe how the multidisciplinary approach could be the best way to manage difficult cases of implant-prosthetic rehabilitation. How to rehabilitate with fixed prosthesis on natural teeth and dental implants a smoker patient who presents with active periodontitis, multiple edentulous areas, dental malocclusion, and severe aesthetic problems was also described. PMID:28421148

A comparison of neural network and fuzzy clustering techniques in segmenting magnetic resonance images of the brain.

PubMed

Hall, L O; Bensaid, A M; Clarke, L P; Velthuizen, R P; Silbiger, M S; Bezdek, J C

1992-01-01

Magnetic resonance (MR) brain section images are segmented and then synthetically colored to give visual representations of the original data with three approaches: the literal and approximate fuzzy c-means unsupervised clustering algorithms, and a supervised computational neural network. Initial clinical results are presented on normal volunteers and selected patients with brain tumors surrounded by edema. Supervised and unsupervised segmentation techniques provide broadly similar results. Unsupervised fuzzy algorithms were visually observed to show better segmentation when compared with raw image data for volunteer studies. For a more complex segmentation problem with tumor/edema or cerebrospinal fluid boundary, where the tissues have similar MR relaxation behavior, inconsistency in rating among experts was observed, with fuzz-c-means approaches being slightly preferred over feedforward cascade correlation results. Various facets of both approaches, such as supervised versus unsupervised learning, time complexity, and utility for the diagnostic process, are compared.

Methods for determining the antimicrobial susceptibility of mycobacteria.

PubMed

Alcaide, Fernando; Esteban, Jaime; González-Martin, Julià; Palacios, Juan-José

2017-10-01

Mycobacteria are a large group of microorganisms, multiple species of which are major causes of morbidity and mortality, such as tuberculosis and leprosy. At present, the emergence and spread of multidrug-resistant strains of Mycobacterium tuberculosis complex are one of the most serious health problems worldwide. Furthermore, in contrast to M. tuberculosis and Mycobacterium leprae, non-tuberculous mycobacteria (NTM) are more frequently isolated and, in many cases, treatment is based on drug susceptibility testing. This article is a review of the different methods to determine the in vitro drug susceptibility of M. tuberculosis complex and the most relevant NTM isolates. The molecular techniques currently used for rapid detection of resistance of clinical specimens are also analysed. Copyright © 2016 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

[Shared decision-making and individualized goal setting - a pilot trial using PRISM (Pictorial Representation of Illness and Self Measure) in psychiatric inpatients].

PubMed

Büchi, S; Straub, S; Schwager, U

2010-12-01

Although there is much talk about shared decision making and individualized goal setting, there is a lack of knowledge and knowhow in their realization in daily clinical practice. There is a lack in tools for easy applicable tools to ameliorate person-centred individualized goal setting processes. In three selected psychiatric inpatients the semistructured, theory driven use of PRISM (Pictorial Representation of Illness and Self Measure) in patients with complex psychiatric problems is presented and discussed. PRISM sustains a person-centred individualized process of goal setting and treatment and reinforces the active participation of patients. The process of visualisation and synchronous documentation is validated positively by patients and clinicians. The visual goal setting requires 30 to 45 minutes. In patients with complex psychiatric illness PRISM was used successfully to ameliorate individual goal setting. Specific effects of PRISM-visualisation are actually evaluated in a randomized controlled trial.

Improved multi-objective ant colony optimization algorithm and its application in complex reasoning

NASA Astrophysics Data System (ADS)

Wang, Xinqing; Zhao, Yang; Wang, Dong; Zhu, Huijie; Zhang, Qing

2013-09-01

The problem of fault reasoning has aroused great concern in scientific and engineering fields. However, fault investigation and reasoning of complex system is not a simple reasoning decision-making problem. It has become a typical multi-constraint and multi-objective reticulate optimization decision-making problem under many influencing factors and constraints. So far, little research has been carried out in this field. This paper transforms the fault reasoning problem of complex system into a paths-searching problem starting from known symptoms to fault causes. Three optimization objectives are considered simultaneously: maximum probability of average fault, maximum average importance, and minimum average complexity of test. Under the constraints of both known symptoms and the causal relationship among different components, a multi-objective optimization mathematical model is set up, taking minimizing cost of fault reasoning as the target function. Since the problem is non-deterministic polynomial-hard(NP-hard), a modified multi-objective ant colony algorithm is proposed, in which a reachability matrix is set up to constrain the feasible search nodes of the ants and a new pseudo-random-proportional rule and a pheromone adjustment mechinism are constructed to balance conflicts between the optimization objectives. At last, a Pareto optimal set is acquired. Evaluation functions based on validity and tendency of reasoning paths are defined to optimize noninferior set, through which the final fault causes can be identified according to decision-making demands, thus realize fault reasoning of the multi-constraint and multi-objective complex system. Reasoning results demonstrate that the improved multi-objective ant colony optimization(IMACO) can realize reasoning and locating fault positions precisely by solving the multi-objective fault diagnosis model, which provides a new method to solve the problem of multi-constraint and multi-objective fault diagnosis and reasoning of complex system.

Qualitative review of usability problems in health information systems for radiology.

PubMed

Dias, Camila Rodrigues; Pereira, Marluce Rodrigues; Freire, André Pimenta

2017-12-01

Radiology processes are commonly supported by Radiology Information System (RIS), Picture Archiving and Communication System (PACS) and other software for radiology. However, these information technologies can present usability problems that affect the performance of radiologists and physicians, especially considering the complexity of the tasks involved. The purpose of this study was to extract, classify and analyze qualitatively the usability problems in PACS, RIS and other software for radiology. A systematic review was performed to extract usability problems reported in empirical usability studies in the literature. The usability problems were categorized as violations of Nielsen and Molich's usability heuristics. The qualitative analysis indicated the causes and the effects of the identified usability problems. From the 431 papers initially identified, 10 met the study criteria. The analysis of the papers identified 90 instances of usability problems, classified into categories corresponding to established usability heuristics. The five heuristics with the highest number of instances of usability problems were "Flexibility and efficiency of use", "Consistency and standards", "Match between system and the real world", "Recognition rather than recall" and "Help and documentation", respectively. These problems can make the interaction time consuming, causing delays in tasks, dissatisfaction, frustration, preventing users from enjoying all the benefits and functionalities of the system, as well as leading to more errors and difficulties in carrying out clinical analyses. Furthermore, the present paper showed a lack of studies performed on systems for radiology, especially usability evaluations using formal methods of evaluation involving the final users. Copyright © 2017 Elsevier Inc. All rights reserved.