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Biomedical subjects

K Smith

Publications and source records attributed to K Smith.

At least 181 records · Page 10Linked to original sources
PubMed1998

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review.

CONTEXT: Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes. OBJECTIVE: To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes. DATA SOURCES: We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted. STUDY SELECTION: Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control. DATA EXTRACTION: The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings. DATA SYNTHESIS: A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect. CONCLUSIONS: Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.

Clinical Competence↗
PubMed1998

Partial clone of the gene for AS protein of the lamprey Petromyzon marinus, a member of the albumin supergene family whose expression is restricted to the larval and metamorphic phases of the life cycle.

AS was previously found to be a liver-synthesized serum protein that is found in the larval (ammocoete), metamorphosing, and juvenile individuals during the life cycle of Petromyzon marinus but not in the sexually mature upstream-migrant individuals (Filosa et al. [1982] Comp. Biochem. Physiol., 72B:521-530; [1986] Comp. Biochem. Physiol., 83B:143-149; Ito et al. [1988] J. Exp. Zool., 245:256-263). In the present work, a partial clone for the gene for the AS protein was isolated from a cDNA expression library made from ammocoete liver. Northern blots using this clone showed hybridization with mRNA from the intervals of the life cycle prior to the upstream-migration period but not from the upstream-migration period itself. The cloned DNA was sequenced and the deduced amino acid sequence was found to have 40% identity with an albumin (our SDS-1 protein) from the upstream migrants of P. marinus (Gray and Doolittle, [1992] Protein Sci., 1:289-302), which is homologous to mammalian serum albumin. Thus the lamprey has two genes, AS and SDS-1, that code for different but similar albumin-like proteins, which predominate at different phases in its life cycle. It is suggested that AS protein, because it is present only at the earlier phases of the life cycle and because its gene is transcribed only during this same period, may be an early version of the alpha-fetoprotein (AFP) of mammals that is found only in the embryonic, fetal, and neonatal phase of their life cycle.

Albumins↗
PubMed1998

Pretreatment with intralesional hyaluronidase prior to excision of dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSPs) are an uncommon malignancy that commonly recur, but rarely metastasize. The origin of DFSPs is controversial; however, they stain with the progenitor marker CD34. DFSPs usually show increased stromal mucin, mainly hyaluronic acid (HA). HA increases cellular proliferation, delays differentiation and increases cellular motion. We evaluated the pretreatment of DFSPs with intralesional injections of hyaluronidase (HD) prior to the surgical excision. Five of nine cases of DFSPs were pretreated with HD. In HD-pretreated cases the margins for excision of the residual tumor were reduced. HD pretreatment also decreased CD34 staining and increased polarizable collagen in the residual tumor.

Adult↗
PubMed1998

Case-control study of childhood leukaemia and cancer in Scotland: findings for neonatal intramuscular vitamin K.

OBJECTIVE: To test the hypothesis of an association between neonatal intramuscular vitamin K and childhood leukaemia and other cancers. DESIGN: Population based case-control study with data abstracted from hospital records. SETTING: Scotland. SUBJECTS: Children aged 0-14 years resident in Scotland from 1991-4 and diagnosed with leukaemia (150), lymphomas (46), central nervous system tumours (79), a range of other solid tumours (142), and a subset of acute lymphoblastic leukaemia (129). Controls were 777 children matched for age and sex, providing 417 matched sets (360 triplets and 57 pairs) for analysis. MAIN OUTCOME MEASURE: Odds ratios for the risk of childhood leukaemia and cancer and intramuscular vitamin K versus a combined group of oral doses, none, and no record. Results are given for information recorded in medical notes and data supplemented by hospital policy. RESULTS: Odds ratios based on medical record abstractions showed no significant positive association for leukaemias (odds ratio 1.30; 95% confidence interval 0.83 to 2.03), acute lymphoblastic leukaemia (1.21; 0.74 to 1.97), lymphomas (1.06; 0.46 to 2.42), central nervous system tumours (0.74; 0.40 to 1.34), and other solid tumours (0.59; 0.37 to 0.96). There was no association with acute lymphoblastic leukaemia in children aged 1 to 6 years. Imputation of exposure from hospital policy gave similar results. Adjustment for deprivation and type of delivery moved risk estimates closer to unity for all major diagnostic groups. CONCLUSIONS: The observation of an increased risk of childhood leukaemia and cancer associated with intramuscular vitamin K is not confirmed by this independent population based study.

Adolescent↗
PubMed1998

Orgaran during rotational atherectomy in the setting of heparin-induced thrombocytopenia.

Heparin is considered necessary during percutaneous coronary interventions; however, heparin is contraindicated in patients with heparin-induced thrombocytopenia and/or heparin antibodies. We describe the successful use of the heparinoid Orgaran (danaparoid sodium) in addition to abciximab (ReoPro) in a patient with heparin antibodies who required rotational atherectomy.

Abciximab↗
PubMed1998

A model for making outcomes research standard practice in clinical dietetics.

In today's rapidly changing health care environment, it is imperative that dietitians demonstrate the importance of their role as health care providers by initiating and participating in outcomes research. Patient care should be based on empirical studies, and clinical dietitians should participate in or be at the helm of such investigations. Nutrition research is usually accomplished and reported by persons with MD or PhD degrees who do not have clinical training in nutrition and does not often address situations encountered by dietitians in clinical settings. This article examines the extent to which clinical dietitians are conducting and reporting outcomes research, their attitudes about such research, and how they think they could best acquire the skills needed to incorporate outcomes research into their practice. Results indicate that clinical dietitians are not writing a substantial percentage of articles and that reports of outcomes research are not commonly included in clinical nutrition journals. Clinical dietitians appear to value the inclusion of research in clinical practice, but they are not spending a great amount of time doing research. Dietitians report being comfortable about participating in research but not about designing, conducting, and reporting research. Results from several surveys were used to develop a model for integrating research in clinical practice. This model includes the research process as a basis for clinical practice. A model for collaborative efforts between clinical and academic dietitians is also proposed and emphasizes the responsibility of academic dietetics training programs in the integration of research and clinical practice.

Attitude of Health Personnel↗
PubMed1998

Effect of major abdominal operations on energy and protein metabolism in infants and children.

PURPOSE: The authors attempted to test the hypothesis that infants and children increase whole-body protein flux and energy metabolism during the early postoperative period. METHODS: Ten infants and children (age range, 2 days to 3 years; weight range, 1.5 to 14.2 kg) who had undergone a major operation were studied. Anaesthesia was standardised, and operative stress score (OSS) recorded. Patients were studied for 4 hours preoperatively and for the first 6 hours after surgery. Respiratory gas exchange was measured by computerised indirect calorimetry. The components of whole-body protein turnover were estimated by giving an intravenous infusion of [1-13C]leucine, and by measuring the isotopic enrichment of plasma [13C]alpha-ketoisocaproic acid by gas chromatograph mass spectrometry and 13CO2 enrichment by isotope ratio mass spectrometry. RESULTS: Median duration of the operation was 73.5 minutes (range, 28 to 285 minutes) with a OSS of 8 (range, 7-17). There were no significant differences in oxygen consumption and resting energy expenditure between the two study phases. The respiratory quotient (RQ) fell from a preoperative value of 0.92 (range, 0.81 to 1.08) to 0.89 (range, 0.79 to 0.95) postoperatively (P = .04). The authors found no significant differences in the rates of whole body protein flux, protein synthesis, amino acid oxidation, and protein degradation between the study phases. CONCLUSIONS: Infants and children do not increase their whole-body protein turnover and metabolic rate after major operations. The observed decrease in RQ reflects mobilisation of endogenous fat. We speculate that the lack of catabolism observed in children is caused by a diversion of protein synthesis from growth to tissue repair.

Abdomen↗
PubMed1998

Sexual Assault Response Team: overcoming obstacles to program development.

After several years of planning, The SART at Immanuel St. Joseph's--Mayo Health Systems became a reality in August 1997. The nurses who were trained for this program were already providing 24-hour coverage in the emergency department for psychiatric emergencies and patients with chemical dependency. The SANE responsibilities were added to their on-call duties. Five nurses participated in a 40-hour training program by SANE specialists and experts in the local community. As expected, nurses were apprehensive as they conducted their first examinations; however, all has gone well. Over time, the providers' and clients' satisfaction with the program has improved. The examination is completed in less time, and the person assaulted does not have to wait as long for the SANE to arrive. Members of law enforcement and the prosecutor's office are especially pleased with the quality of evidence collected and the procedures followed to maintain chain of evidence so the evidence obtained can be used in prosecution. The program has resulted in kind and compassionate care for persons who have been sexually assaulted. The providers are continuing to meet monthly as an interdisciplinary, interagency team and are addressing concerns as they arise. Members of the SART are developing a good working relationship. Everyone involved agrees that developing this program has been a worthwhile effort and that the hospital is providing a valued service for the community.

Emergency Nursing↗
PubMed1998

Assessment of cancellous bone quality in severe osteoarthrosis: bone mineral density, mechanics, and microdamage.

The role of bone microdamage (microscopic cracks or microcracks and ultrastructural collagen matrix and bone mineral damage) in diseases such as osteoarthrosis and osteoporosis is poorly understood. Microdamage accumulation in vivo is influenced by age and cyclic loading, therefore, it would be useful if the burden of microdamage in bone could be assessed by noninvasive measures such as the radiological measurement of bone mineral density (BMD). The aim of this study was to investigate the relationship between BMD, compressive strength and stiffness, and microdamage in the cancellous bone of the proximal femur in patients with severe osteoarthrosis. Trabecular bone core samples, from the intertrochanteric region of the femur, were obtained from 34 patients, with a mean age of 70.3 +/- 11.1 years, undergoing total hip arthroplasty for osteoarthrosis. Cores selected from contact X-ray images were used for BMD measurement, compressive mechanical testing or left untested (uncrushed), en bloc staining for microdamage, and bone histomorphometry. The study shows a strong dependence of both the elastic modulus and ultimate failure stress of the bone samples on BMD and a significant relationship between the elastic modulus and trabecular anisotropy (Tr. An). In multiple linear regression, BMD and Tr. An together account for about 70% of the variance in the elastic modulus. Then including microcrack crack density (Cr.Dn) and damage volume fraction (DxV/BV) variables, Tr. An alone accounts for a relatively small amount of the variation (8.5%) in ultimate failure stress and elastic modulus. The Cr.Dn accounts for more of the variation in the ultimate failure stress than in the elastic modulus (50% vs. 7%). In this experiment, data for Cr.Dn provide a measure of damage associated with the ultimate failure of cancellous bone. In specimens that were not mechanically tested, in vivo microcrack accumulation increases exponentially with age. In conclusion, data from this study suggest that BMD and Cr.Dn are the major determinants of cancellous bone strength, whereas BMD and Tr. An are major determinants of cancellous bone stiffness. In bone specimens subjected to compressive testing there was no relationship between microdamage and BMD, suggesting that BMD cannot be used to monitor changes in the mechanical properties of bone due to microdamage accumulation.

Absorptiometry, Photon↗
PubMed1998

Three-dimensional confocal images of microdamage in cancellous bone.

The accumulation of microdamage in bone may contribute to loss of bone quality in osteoporosis, and the role of microdamage in the etiology of fatigue fractures is unknown. Microdamage created during testing, ex vivo, can increase the fragility of bone by decreasing the load necessary to cause fracture. Microdamage can also accumulate in vivo, but its influence on bone fragility is unknown. To date, stained microcracks are the only criteria to have been correlated with bone mechanics, leaving the influence of ultrastructural damage on bone fragility open for scrutiny. Staining en bloc has identified three morphological features in the tissue, discrete microcracks, cross-hatch staining, and diffuse staining. The relationship between these features and their identification as microdamage remains equivocal. The purpose of this study was to investigate the three-dimensional nature of microdamage in cancellous bone and also to describe stained microcracks, cross-hatch staining, and diffuse staining and to determine whether they all relate to microdamage in bone. Laser scanning confocal microscopy that provides improved spatial resolution over bright-field microscopy was used to visualize bone damage. It was found that crack surface density was highly correlated with crack density (r = 0.95, p < 0.0001), suggesting that the crack surface of preexisting cracks increases as new cracks are formed or submicroscopic cracks become visible under bright-field microscopy. Cross-hatch staining and diffuse staining included ultra-microcracks about 10 microm in length. The ultra-microcracks in cross-hatch staining were organized in bands and surrounded by diffuse staining. This study demonstrates that damage in bone occurs over a wide range and that discrete microcracks, cross-hatch staining, and diffuse staining are all indicative of bone damage. The diffuse staining still evident in association with the ultra-microcracks seen in cross-hatch staining and diffuse staining is probably due to damage at a still smaller scale than we have been able to investigate.

Adult↗
PubMed1998

Farming, marketing, and changes in the authority of elders among pastoral Rendille and Ariaal.

Pastoral cultures of East Africa include certain institutions that meet requirements for labor organization and control over resources. Institutions that have been adapted to multi-species pastoralism in arid or semi-arid environments include: a patriarchical and gerontocratic control over resources that permits polygyny; an age-system that both dictates work roles and legitimizes control over resources; and marriage practices that permit elder males to control the labor of unmarried junior males. All of these institutions and ideals are interrelated, reinforcing each other and perpetuating the social and ideological order of society. When the economy changes, however, institutions may also change or perhaps become less useful for organizing society. Such is the case for Rendille and Ariaal of northern Kenya who now farm and are more involved in the market economy than their pastoral kin. The result is greater economic opportunity for young men of the warrior age grade, while ways for elders to maintain their authority continue to exist.

Journal Article↗
PubMed1998

Differential expression of vascular endothelial growth factor mRNA vs protein isoform expression in human breast cancer and relationship to eIF-4E.

Angiogenesis is the formation of new blood vessels from the existing vasculature. Vascular endothelial growth factor (VEGF) is an endothelium-specific angiogenic factor strongly implicated in pathological angiogenesis. In this study, the mRNA and protein expression of the four alternatively spliced VEGF isoforms (121, 165, 189 and 206 amino acids) were examined in normal and malignant breast tissues. Three VEGF transcripts were detected in both (121>165>189), whereas only VEGF165 protein was detected. The tumours expressed more VEGF mRNA (P = 0.02) and protein (P < 0.0001), with eight-fold more VEGF protein generated per mRNA unit (P = 0.009). To examine this further, the expression of eIF-4E, a translation initiation factor, was examined. Increased eIF-4E mRNA levels were detected in the tumours (P < 0.0001) that correlated with VEGF mRNA (P = 0.0002), implying co-regulation of these genes. VEGF mRNA expression was elevated in tumours expressing the epidermal growth factor receptor (P < 0.01), but there was no difference according to oestrogen receptor status (P = 0.9), node status (P = 0.09) or between differing histologies (P = 0.4). These data suggest that elevated VEGF protein expression, by both enhanced transcription and translation, is a potential means by which tumour angiogenesis is induced in breast carcinomas. VEGF expression is also significantly associated with factors correlating with a poor outcome, implying a role in progression of this disease.

Adult↗
PubMed1998

Regulation of Wnt5a expression in human mammary cells by protein kinase C activity and the cytoskeleton.

The Wnts can be classified into two classes based on their ability to transform cells. The Wnt5a class can antagonize the effects of transforming Wnts partly through effects on cell migration. To understand the mechanisms of regulation of Wnt5a, we investigated its expression in human normal and breast cancer cell lines. Elevation of Wnt5a in HB2, a normal breast epithelial cell line, was linearly correlated with cell density, but this did not occur in cancer cell lines. We examined intracellular events responsible for the regulation of Wnt5a by cell to cell contacts, using various metabolic agents known to affect signal transduction pathways. Agents that selectively blocked protein kinase C (calphostin C) or protein tyrosine kinases (genistein) reduced the level of Wnt5a expression markedly. Protein kinase C activation by phorbol 12-myristate 13-acetate up-regulated Wnt5a partly through prolongation of Wnt5a mRNA half-life. Cytoskeleton reorganization following cytochalasin D treatment caused an induction of Wnt5a, which was associated with changes in cell morphology. Calphostin C did not block these effects, showing that protein kinase C is acting upstream of cytoskeletal modulation. However, the cancer cell lines treated with cytochalasin D showed no changes in cell morphology or Wnt5a induction, suggesting disruption of this regulatory pathway in cancer.

Breast↗