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A blogger in their midst.

It was five minutes before show time, and only 15 people had wandered into the conference room to hear Lancaster-Webb CEO Will Somerset introduce the company's latest line of surgical gloves. More important, sales prospect Samuel Taylor, medical director of the Houston Clinic, had failed to show. Will walked out of the ballroom to steady his nerves and noticed a spillover crowd down the hall. He made a "What's up?" gesture to Judy Chen, Lancaster-Webb's communications chief. She came over to him. "It's Glove Girl. You know, the blogger," Judy said, as if this explained anything. "I think she may have stolen your crowd." "Who is she?" Will asked. Glove Girl was a factory worker at Lancaster-Webb whose always outspoken, often informative postings on her Web log had developed quite a following. Will was new to the world of blogging, but he quickly learned about its power in a briefing with his staff. After Glove Girl had raved about Lancaster-Webb's older SteriTouch disposable gloves, orders had surged. More recently, though, Glove Girl had questioned the Houston Clinic's business practices, posting damaging information at her site about its rate of cesarean deliveries--to Sam Taylor's consternation. This fictional case study considers the question of whether a highly credible, but sometimes inaccurate and often indiscreet, on-line diarist is more of a liability than an asset to her employer. What, if anything, should Will Somerset do about Glove Girl? Four commentators--David Wein-berger, author of Small Pieces Loosely Joined; Pamela Samuelson, a professor of law and information management at the University of California, Berkeley; Ray Ozzie, CEO and chairman of Groove Networks; and Erin Motameni, vice president of human resources at EMC-offer expert advice.

Administrative Personnel↗

OCCUPATIONAL HEALTH. ITS ROLE IN ENVIRONMENTAL HEALTH PROGRAMS.

An important part of the practice of occupational medicine is directed toward the control of the industrial, physical, chemical and biological environments which may adversely affect health. This concern with the effect of environment on health has moved out of industry and has become a major area of public health practice, as evidenced by interest in pesticides, air pollution and radioactive fallout. The discipline of occupational health is a natural resource and springboard for the development of the skills necessary to control these environmental hazards. Occupational health is supplying trained and experienced personnel in the applied technical and administrative phases. It also can provide a basis for graduate teaching and research programs in environmental health. At the University of California's School of Public Health in Berkeley, curricula are being developed for educating teachers and research personnel in the environmental health sciences.

Air Pollution↗

VIROLOGY. A REPORT OF PRESENTATIONS FEATURED AT THE 94TH ANNUAL SESSION OF THE CALIFORNIA MEDICAL ASSOCIATION.

With virology as the theme of its three general meetings, the 94th Annual Session of the California Medical Association was addressed by outstanding experts on various aspects of this engaging subject. The following report of highlights of the speakers' presentations was written at the editor's behest by Warren Levinson, M.D., a postdoctoral fellow at the Virus Laboratory, University of California, Berkeley.

California↗

Persistent mammary hyperplasia in FVB/N mice.

The inbred FVB/N mouse strain is widely used for creating transgenic mice. Over the past decade, persistent mammary hyperplasia has been detected in many multiparous FVB/N female mice sent to the University of California, Davis (UCD) Mutant Mouse Pathology Laboratory (MMPL) by a number of different laboratories. However, the experimental details concerning most specimens were not always available. To confirm these empiric findings, experiments were carried out to evaluate the mammary glands of FVB/N mice under controlled conditions. Persistent mammary hyperplasia that related to parity was found. Weeks after their first to fourth pregnancy, 10 FVB/N female mice from the Lawrence Berkeley National Laboratory (LBNL) colony were studied and the mammary glands were evaluated. The percentage of fat pad filled was estimated, using image analysis. Serum samples and the pituitary gland from other FVB/N mice from the LBNL were assayed for prolactin concentration. Multiparous FVB/N females consistently had persistent mammary hyperplasia. Four of seven females in the LBNL colony had hyperplasia after three pregnancies. A few foci of squamous nodules and sporadic carcinomas also were observed. Thus, some FVB/N females may have persistent mammary hyperplasia after three pregnancies without detectable pituitary abnormalities. Mammary carcinomas also may develop sporadically. These background phenotypes must be considered when interpreting the effect of genetic manipulation in FVB/N mice.

Animals↗

Personal renewal.

After John Gardner's presentation on "Self-Renewal" to THE WESTERN JOURNAL OF MEDICINE Editors' Meeting, (*) Joseph Murphy, MD, Special Editor for Wyoming, asked the former Secretary of Health, Education, and Welfare, "Where are you in your life's cycle?" Dr Gardner, who is 80 years old, answered, "When Chief Justice Oliver Wendell Holmes, Jr, was in his 90s, he was asked a similar question and said, ;I'm like a race horse cantering along after the race is over, cooling down.' Well, I'm nowhere near cantering! I'm still in the race, pushing the world." race, pushing the world."John Gardner, who received his undergraduate degree from Stanford and PhD from the University of California, Berkeley, taught at the college level for several years before he joined the Carnegie Foundation. As president of Carnegie Corporation and Carnegie Foundation for the Advancement of Teaching, he began to "push the world" toward education and in 1964 received the country's highest civilian honor, the Presidential Medal of Freedom. He has also pushed it toward political reform by founding Common Cause, toward grass-roots political action by founding the Urban Coalition, toward leadership training by founding the White House Fellows program, and toward volunteerism by founding the Independent Sector (a coalition of for-profit and not-for-profit organizations and foundations). His books, including Excellence, Self-Renewal, No Easy Victories, and On Leadership, have pushed readers to new understanding of themselves and of organizations to higher levels of creativity and energy to get important work done. His current research focuses on discovering and defining the characteristics of healthy, vital communities. His call to "keep on keeping on," indeed, to push the world, leads to constructive change. Active people become effective people, infused with the energy and optimism that good hard work inspires. I think you will find this paper as invigorating to read as it was to hear.

Aging↗

High-performance computing, high-speed networks, and configurable computing environments: progress toward fully distributed computing.

The next several years will see the maturing of a collection of technologies that will enable fully and transparently distributed computing environments. Networks will be used to configure independent computing, storage, and I/O elements into "virtual systems" that are optimal for solving a particular problem. This environment will make the most powerful computing systems those that are logically assembled from network-based components and will also make those systems available to a widespread audience. Anticipating that the necessary technology and communications infrastructure will be available in the next 3 to 5 years, we are developing and demonstrating prototype applications that test and exercise the currently available elements of this configurable environment. The Lawrence Berkeley Laboratory (LBL) Information and Computing Sciences and Research Medicine Divisions have collaborated with the Pittsburgh Supercomputer Center to demonstrate one distributed application that illuminates the issues and potential of using networks to configure virtual systems. This application allows the interactive visualization of large three-dimensional (3D) scalar fields (voxel data sets) by using a network-based configuration of heterogeneous supercomputers and workstations. The specific test case is visualization of 3D magnetic resonance imaging (MRI) data. The virtual system architecture consists of a Connection Machine-2 (CM-2) that performs surface reconstruction from the voxel data, a Cray Y-MP that renders the resulting geometric data into an image, and a workstation that provides the display of the image and the user interface for specifying the parameters for the geometry generation and 3D viewing. These three elements are configured into a virtual system by using several different network technologies. This paper reviews the current status of the software, hardware, and communications technologies that are needed to enable this configurable environment. These interdependent technologies include: (1) user interface and application program construction methodologies, (2) the interprocess communication (IPC) mechanisms used to connect the software modules of the application, (3) the network protocols and interface hardware used by the IPC for communicating between modules running on separate and independent computing system elements, (4) the telecommunications infrastructure that provides the low-level data transfer functions for the networks that connect the geographically distributed elements used by the application, and (5) the nature of the functional elements that will be connected to form virtual systems.

Computer Communication Networks↗

Crossing the quality chasm: implications for health services administration education.

Programs in Health Services Administration (HSA) should respond to the mandate to improve patient care as put forth by the Institute of Medicine (IOM) and other reports on the proliferation and consequences of medical errors. This article will identify a framework to base curriculum change, competency areas, and educational methods to impart quality improvement knowledge and skills. The first six competency areas reflect the six redesign imperatives from the IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001): redesign of the care process; use of information technologies; knowledge and skills management; development of effective teams; coordination of care; and use of performance and outcomes measurement. Based on a literature review, five additional areas were identified: strategic quality planning; programs for patient safety and risk management; change management; roles of stakeholders, payers and regulators; and development of a learning environment and blame-free culture. Examples of curriculum content are provided from HSA programs at Georgetown University, University of Washington, and University of California at Berkeley.

Clinical Competence↗

Characterization of a Mycobacterium ulcerans-like infection in a colony of African tropical clawed frogs (Xenopus tropicalis).

A nontuberculous Mycobacterium ulcerans-like organism was identified as the causative agent of an epizootic of mycobacteriosis in a colony of African tropical clawed frogs, Xenopus (Silurana) tropicalis, at the University of California, Berkeley. Diverse clinical signs of disease were observed, including lethargy, excess buoyancy, coelomic effusion, cutaneous ulcers, and granulomas. Visceral granulomas, ulcerative and granulomatous dermatitis, coelomitis, and septicemia were common findings at necropsy. Identification of M. ulcerans-like organisms was based on molecular and phenotypical characteristics. The findings of this investigation indicate that this M. ulcerans-like organism is a primary cause of morbidity and mortality in aquatic anurans and should be considered in the differential diagnosis of coelomic effusion in amphibians. Furthermore, if this Mycobacterium species ultimately is identified as M. ulcerans, X. tropicalis should be considered a potential source of this important public health pathogen.

Animals↗

A corpus driven approach applying the "frame semantic" method for modeling functional status terminology.

In an effort to unearth semantic models that could prove fruitful to functional-status terminology development we applied the "frame semantic" method, derived from the linguistic theory of thematic roles currently exemplified in the Berkeley "FrameNet" Project. Full descriptive sentences with functional-status conceptual meaning were derived from structured content within a corpus of questionnaire assessment instruments commonly used in clinical practice for functional-status assessment. Syntactic components in those sentences were delineated through manual annotation and mark-up. The annotated syntactic constituents were tagged as frame elements according to their semantic role within the context of the derived functional-status expression. Through this process generalizable "semantic frames" were elaborated with recurring "frame elements". The "frame semantic" method as an approach to rendering semantic models for functional-status terminology development and its use as a basis for machine recognition of functional status data in clinical narratives are discussed.

Information Science↗

The case of the missing third.

How is it that form arises out of chaos? In attempting to deal with this primary question, time and again a "Missing Third" is posited that lies between extremes. The problem of the "Missing Third" can be traced through nearly the entire history of thought. The form it takes, the problems that arise from it, the solutions suggested for resolving it, are each representative of an age. This paper traces the issue from Plato and Parmenides in the 4th--5th centuries, B.C.; to Neoplatonism in the 3rd--5th centuries; to Locke and Descartes in the 17th century; on to Berkeley and Kant in the 18th century; Fechner and Wundt in the 19th century; to behaviorism and Gestalt psychology, Jung, early in the 20th century, ethology and cybernetics later in the 20th century, then culminates late in the 20th century, with chaos theory.

Animals↗

Meditation can reduce habitual responding.

CONTEXT: Although cognitive aspects of meditation underlie much of its clinical application, very little research has examined meditation's cognitive consequences. This investigation provides experimental support for the idea that meditation leads to a reduction in habitual responding using randomly selected subjects, a secular form of meditation, and a full experimental design. OBJECTIVE: To test the hypothesis that meditation leads to a reduction in habitual responding. DESIGN: Studies 1 and 2 each incorporated pre-test and post-test designs with a 20-minute intervening attention task (meditation, rest, or a cognitive control). SETTING: Yale University in New Haven, Conn, and the University of California, Berkeley. PARTICIPANTS: One hundred and twenty and 90 undergraduates participated in Studies 1 and 2, respectively. MAIN OUTCOME MEASURES: Stroop and Word Production (category generation and stem-completion) tasks assessed habitual responding in Study 1. Galvanic Skin response measured arousal in Study 1. The category generation task assessed habitual responding in Study 2. Tellegen's Absorption Scale (TAS) measured attention ability. RESULTS: In Study 1, meditation participants showed a reduction in habitual responding on the Stroop task as compared to controls. Study 1 revealed no statistically significant effects in the word production task. Stroop task performance was not mediated by arousal reduction. In Study 2, meditation participants showed a reduction in habitual responding on the category production task. Specifically, when participants generated either typical or atypical items, on average, meditation participants produced more atypical items than controls. Category production performance was not mediated by Tellegen's Absorption Scale (TAS) scores. Overall, high TAS scores were related to atypical responding. CONCLUSION: Across cognitive tasks, when participants understood that the goal was to respond non-habitually, meditation reduced habitual responding.

Adult↗

The environment as a support system for independent living.

In extended interviews and visits with 150 physically disabled young adults living independently in Berkeley, CA, the author studied the environment as they experienced it and evaluated its accommodation to their special needs. The environment in this study is considered in physical and psychosocial terms, that is, as a support system for the multifaceted needs of the whole person. The framework for organizing the data was Mayer Spivak's construct of "archetypal place" in which he defines 13 fundamental places in terms of the behaviors they support: shelter, sleep, mate, groom, feed, excrete, store, territory, play, route, meet, compete, and work. For purposes of the present work, shelter and mate are discussed--shelter, because of the clarity of its relationship between existence and physical form, and mate because of its more abstract relevance to physical form.

Activities of Daily Living↗

[Stereotactic convergent-beam irradiation: its current prospects based on clinical results].

"Radiosurgery" is the term for a special concept in radiotherapy. It describes a percutaneous, stereotactically guided irradiation delivering a single high dose with collimated narrow beams. The precise stereotactic localization of the target point and a steep dose gradient outside the target volume allow the administration of high doses to a lesion without damage to adjacent normal tissue. Risk of necrosis, due to a dose volume relationship represents the limits of radiosurgery. Units for radiosurgery were designed at Stockholm using multiple external cobalt-60-gamma sources, at Boston operating with protons of a cyclotron, at Berkeley operating with helium ions accelerated by a synchrocyclotron. An attractive alternative to these complicated and expensive facilities is the use of a modified linear accelerator. At the German Cancer Research Center in Heidelberg such a system was developed and has been available for the treatment of patients since 1984. Though, data of over 100,000 patients with vascular malformations and cancer disease are available worldwide, the indication for this therapy is validated only for a minority of entities. In cases of inoperable arteriovenous malformations favourable results in achieving obliteration range between 60% and 100% were obtained. Median survival for solitary brain metastases with controlled, extracerebral tumor diseases were between nine and twelve months. Up to now, advantages of stereotactic irradiation for benign tumor masses could not be proven. Therefore, randomized trials should be initiated in this field, considering decisive improvements in local tumor control with techniques of microsurgery and fractionated, postoperative radiotherapy during the last few years.

Brain↗

Improving efficiency of a small forensic DNA laboratory: validation of robotic assays and evaluation of microcapillary array device.

AIM: To present validation studies performed for the implementation of existing and new technologies to increase the efficiency in the forensic DNA Section of the Palm Beach County Sheriff's Office (PBSO) Crime Laboratory. METHODS: Using federally funded grants, internal support, and an external Process Mapping Team, the PBSO collaborated with forensic vendors, universities, and other forensic laboratories to enhance DNA testing procedures, including validation of the DNA IQ magnetic bead extraction system, robotic DNA extraction using the BioMek2000, the ABI7000 Sequence Detection System, and is currently evaluating a micro Capillary Array Electrophoresis device. RESULTS: The PBSO successfully validated and implemented both manual and automated Promega DNA IQ magnetic bead extractions system, which have increased DNA profile results from samples with low DNA template concentrations. The Beckman BioMek2000 DNA robotic workstation has been validated for blood, tissue, bone, hair, epithelial cells (touch evidence), and mixed stains such as semen. There has been a dramatic increase in the number of samples tested per case since implementation of the robotic extraction protocols. The validation of the ABI7000 real-time quantitative polymerase chain reaction (qPCR) technology and the single multiplex short tandem repeat (STR) PowerPlex16 BIO amplification system has provided both a time and a financial benefit. In addition, the qPCR system allows more accurate DNA concentration data and the PowerPlex 16 BIO multiplex generates DNA profiles data in half the time when compared to PowerPlex1.1 and PowerPlex2.1 STR systems. The PBSO's future efficiency requirements are being addressed through collaboration with the University of California at Berkeley and the Virginia Division of Forensic Science to validate microcapillary array electrophoresis instrumentation. Initial data demonstrated the electrophoresis of 96 samples in less than twenty minutes. CONCLUSION: The PBSO demonstrated, through the validation of more efficient extraction and quantification technology, an increase in the number of evidence samples tested using robotic/DNA IQ magnetic bead DNA extraction, a decrease in the number of negative samples amplified due to qPCR and implementation of a single multiplex amplification system. In addition, initial studies show the microcapillary array electrophoresis device (microCAE) evaluation results provide greater sensitivity and faster STR analysis output than current platforms.

California↗

[From Fredrickson's classification of phenotypes--lipoprotein patterns--to genotype comprehension].

First, we will review the major episodes of the initial clinical investigations on lipoproteins. They were carried out in the 1950s, decade of the expansion of Biochemistry. Gofman and his colleagues, at Berkeley, established the power and versatility of the ultracentrifugation method to study the serum lipoproteins. This research group identified Low Density Lipoprotein cholesterol, rather than generic cholesterol as the atherogenic agent. In 1955, Havel et al. at Bethesda, reported a simpler method for the separation of serum lipoproteins by preparative ultracentrifugation, which permitted chemical analysis of defined fractions. However, there was an obvious need for a technique to undertake a screening of a population because the epidemiological Framingham Study, started in 1946, had confirmed serum cholesterol levels as a major risk factor of atherosclerosis. In 1967, Fredrickson et al. applying electrophoresis methods to the separation of lipoproteins developed a classification of lipoprotein disorders, which was somewhat controversial, but it is still a reference. Alaupovic, pursuing his apolipoprotein studies, introduced the ABC nomenclature, the one in use today. In 1973, Brown and Goldstein described the LDL receptor and its function on regulating cholesterol homeostasis, laying the foundations of a classification of hyperlipoproteinemias on a genetic basis. Then, we will review the genetic basis of lipoprotein disorders, through the work of several research groups, studying, mainly, mutations leading to hypercholesterolemias; most hypertrygliceridemias are not well defined in genetic terms.

Genotype↗

State Medicaid coverage for tobacco-dependence treatments--United States, 2005.

In 2005, approximately 41 million persons in the United States had health insurance coverage through Medicaid, a federally and state-funded health-care program, managed at the state level, for persons with limited incomes. An estimated 29% of adult Medicaid recipients were current smokers in 2004. The 2000 Public Health Service (PHS) clinical practice guideline recommends that insurance coverage be provided for tobacco-dependence treatments, including both medication (i.e., bupropion hydrochloride or nicotine patch, gum, inhaler, or nasal spray) and counseling (i.e., individual, group, or telephone). A national health objective for 2010 is to increase insurance coverage of evidence-based treatments for tobacco dependence among all 51 Medicaid programs (objective 27-8). The type of coverage for tobacco-dependence treatments offered by Medicaid has been reported since 1998, and most recently for 2003, from state surveys conducted by the Center for Health and Public Policy Studies at the University of California, Berkeley. All states and the District of Columbia (collectively referred to as states in this report) were resurveyed in 2005 regarding types of coverage and limitations in coverage since 1994. This report summarizes the results of that survey, which indicated that as of December 31, 2005, 1) 38 state Medicaid programs covered some tobacco-dependence treatment (i.e., counseling or medication) for all Medicaid recipients; 2) four states offered coverage only for pregnant women; 3) one state (Oregon) offered coverage for all medication and counseling treatments recommended by the 2000 PHS guideline; and 4) seven states (including Oregon) covered all recommended medications and at least one form of counseling. If the 2010 national health objective is to be achieved, states should offer or increase Medicaid coverage for treatment of tobacco dependence.

Counseling↗

Importance of ventricular arrhythmias in recovery patients with ventricular assist devices.

The effect of ventricular arrhythmias (VA) on survival was retrospectively reviewed in 41 patients (33 men, 8 women) who were supported with Thoratec ventricular assist devices (VAD [Thoratec Medical Inc., Berkeley, CA]) (17 left, 9 right, and 15 biventricular). Ages ranged from 15 to 71 years (mean, 56 years), and duration of support was 0.1-17 days (mean, 4.7 days). There was no significant difference in age, gender, or type of support between survivors and nonsurvivors, and no correlation between the type of support and incidence of VA. Only two patients (both on left ventricular assist devices [LVAD]) died as a direct result of VA. There was no significant difference in the occurrence of VA before or during VAD support between survivors and nonsurvivors. These data show that evidence of VA is not a predictor of survival in patients in whom myocardial recovery is expected.

Adolescent↗

Cost and reimbursement rates for investigational circulatory support.

The clinical evaluation of investigational circulatory support devices has, for the most part, been financed with private funds. St. Louis University initiated a system in 1986 to bill for investigational circulatory support devices and care related to their use. Charges for hospitalization and rates of reimbursement were reviewed in 32 patients who received Thoratec (Thoratec Laboratories Corp., Berkeley, CA [N = 26]), Novacor (Baxter Healthcare Corp., Oakland, CA [N = 4]), or Symbion (Symbion Inc., Tempe, AZ [N = 2]) total artificial heart devices. Duration of support ranged from 0.2 to 440 days (mean 32). Total charges ranged from $43,115 to $1,335,691 (mean $221,716). Charges for the devices and technical support relating directly to their use ranged from $10,305 to $96,030 (mean $28,246). The mean percentage of reimbursement (total charges/total paid) was 67%. Whereas it was uncertain in some patients whether or not the devices were paid for, commercial insurers are willing to reimburse at a high percentage for the total cost of care.

Costs and Cost Analysis↗