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PubMedDate not supplied

Criteria for healthy urban environments.

Indicators derived from a taxonomy of environmental hazards to health can help in assessing the health of a city and its citizens. These criteria may also be related to a city's contribution to the health of its natural environment. The proposed indicators for the city's and the citizens' "sickness" and health are intended to form a matrix, modified by experience. This may generate a database for monitoring changes. Thereafter it could be applied to studies comparing the health of the built environment with that of its human inhabitants, and its natural environment. Ultimately such studies may be used to prevent health hazards to the city and to protect and promote city health. Once the causes of the variables of environmental and human health are determined, attention could also be given to aspects of human health not directly related to those of the city. I discuss the advantages of such a holistic approach over "salad" lists, single theory or issues, and fragmented approaches. The underlying problems of the human condition in cities are so nearly indeterminable and unaddressable that ultimately decisions on policies and their implementations must be based on intuition. However, good intuition works on the best information available.

Canada↗
PubMed1990

[Making a surgical decision: interplay between experience and clinical study].

Although the final, individual decision making in patients always has to be in the hand of the doctor, it has hitherto been much less a matter of scientific analysis than formal decision making on the basis of clinical trials. To change this, several types of individual decision making were characterized, four in the field of intuition (very fast logical decisions, consciously and unconsciously heuristic decisions using special instruments, the deep remainder of intuition which can and should not be the subject of scientific analysis) and discursive (purely logical) decision making as a fifth type. The prospective think-aloud technique including an hierarchical heuristic decision tree was presented as a method for scientific analysis of individual decision making which is open to repetition and criticism. The place of various types of formal trials in this process was defined. Via a posit and the heuristic instrument of representativeness, the problem of the transfer of results from clinical trials to the individual patient was solved.

Clinical Competence↗
PubMed1989

Incorporating hard boxes and soft bubbles into the dietetics curriculum.

Dietitians have been challenged to learn the skills of creative thinking in order to become proficient managers in a rapidly changing world. We reviewed the literature to determine the prerequisites of creative thinking and assessed the management and administrative dietetics curriculum for our dietetic internship to determine whether those prerequisites were being met. A major concern in the dietetics profession is that students are not being adequately prepared to assume top management positions. A review of business school curriculums reveals that an emphasis on management theory and quantitative analysis does not adequately prepare students to function effectively in a world where creative problem solving is required. Effective managers at high levels of responsibility rely on intuition and hunches in addition to logical thought processes. Two thinking models are employed by managers--a rational one (hard box) and an intuitive one (soft bubble). These thinking models, or cognitive styles, can also be defined as left and right brain skills. Effective managers use left and right brain skills plus a combination of the two, or integrative brain skill. We reviewed the competencies, behavioral objectives, and planned experiences for the management level rotations of our dietetic internship to develop a conceptual model for the use of right, left, or integrative thought processes. We discovered that although integrative brain skills are used at all levels of our management rotations, especially the top management rotation, no rotation exclusively fosters right-brain skill development. A dietetic internship offers a fertile environment for developing the creative problem-solving skills that are required in management positions in the health care profession today.(ABSTRACT TRUNCATED AT 250 WORDS)

Administrative Personnel↗
PubMedDate not supplied

[Reinterpretation of the hepatic abscess, a new dimension in abdominal digestive surgery].

Pyogenic abscess of the liver is viewed here as a surgical disease, which appears to raise doubts as to its actual identity. Though located in a given abdominal organ, such abscesses find it hard to recognize this as their exclusive setting and attempt to shrug off these traditional confines. They aspire, rightly or wrongly perhaps, to symbolize a splanchnic context, though, in actual fact, the latter--at least for contingent, doctrinal reasons--is confined to the bipolar liver-bowel system. This context presents its candidacy as playing a leading role in a disease of such importance as to be regarded almost as the "Caudine Forks" of the very process of "surgical" dying. Liver abscess and multiorganic or multisystemic organ failure (MOF or MSOF) might thus be viewed as the two opposite poles (taxonomically definable) of a single clinical condition, which fans out over a broad area and for the most part is only barely known to us. Though is characterized by its abdominal location, it would be all too simple to define the condition as abdominal. In this case, in fact, the abdomen speaks an unusual language, not the habitual, traditional, "spatial" language of location, but the as yet uncertainly articulated "biological" or, why not, even "biosurgical" language of mediation. Is this then a turning point in the pathological field? No, if by that we mean a new concept of the problem. In effect, the concept dates back several centuries and, moreover, darries a heavy burden of responsibility, such as, for instance, having induced the Nobel Prize-winner Elie Metcknicoff (Metcknicoff E., The prolongation of life. London, Heinemann, 1907) to come up with theories appropriated and implemented surgically by Sir William Arbutnot Lane, gaining him nothing but sad notoriety (Gordon R., Great Medical Disasters, Hutchinson, London-Melbourne, 1983). "Concept" is a euphenism, and a more appropriate term might be simply "intuition". The real innovation lies in reviving this old intuition, reinterpreting it now, in fact, as a "concept". The code for this modern interpretation has barely been sketched out in its essentials, but is daily going from strength to strength.(ABSTRACT TRUNCATED AT 400 WORDS)

Endotoxins↗
PubMed1988

Comparing different statistical methods for evaluating diagnostic effectiveness of clinical tests: respiratory distress syndrome as a model.

Phospholipids in specimens of amniotic fluid from 346 patients were quantified and the results evaluated in light of the clinical outcome. Fifty-eight neonates had respiratory distress syndrome. We used this data base to compare different statistical methods for evaluating test effectiveness and diagnostic discrimination. Dichotomizing quantitative tests into binary tests with arbitrary cutoff values was inadequate for comparing test effectiveness. Subgrouping the data into deciles and calculating the incidence of respiratory distress syndrome for each decile avoided the problems of the preceding approach and was easy to calculate and comprehend; however, this method lacked statistical power. Relative operating characteristic curves yielded more statistical power, but results were more difficult to calculate and were not intuitively obvious to most workers in the laboratory. A modified cumulative frequency plot, combining elements of both decile subgrouping and relative operating characteristic curves, was easily calculated and intuitively obvious. These plots, like relative operating characteristic curves, provided an index for quantifying test effectiveness. When used in combination with standard cumulative frequency curves, they also provided direct diagnostic information on disease probability for any value of the clinical assay.

Amniotic Fluid↗
PubMedDate not supplied

Standardized model for diagnosing cervical carcinoma in situ based on the cytologic signs.

An attempt was made to optimize the recognition of cervical intraepithelial carcinoma in situ (CIS) by the adoption of a standard set of rules derived from a case-control study of 50 histologically confirmed incidence cases of CIS and a simple random sample of 100 controls from the same mass screening population examined between 1977 and 1984. One cytotechnologist screened the slides for all occurrences of a standard set of classic cytopathologic signs. Chromatin clumping, dyskeratosis, anisonucleosis and an increased nuclear-cytoplasmic ratio in cells from the deep layer and chromatin clumping and anisonucleosis in cells from the superficial layer showed an association with the diagnosis of CIS, in decreasing order of magnitude. These variables make up a binary discriminant model; adding vacuolization, anisocytosis, prominent nucleoli and multinucleation to this model did not appear to improve its discriminatory power. The discrimination function accommodates any a priori judgment regarding the probability and utility of diagnostic outcomes. Cytologists normally manipulate the probabilities and utilities intuitively; the model requires the translation of intuitive judgments into quantitative estimates. For example, in our cytology laboratory, the CIS pick-up rate is approximately 1 per 1,000 smears; a 1:1,000 negative utility ratio of a false positive versus a false negative is thus used in our model. Given this, our model has a sensitivity of 86% and a specificity of 96% upon reclassification, and its predictive power (true positives/false positives) is 21.5. This standardized cytodiagnosis model is relevant to any local diagnosis-specific probability and utility estimates.

Carcinoma in Situ↗
PubMedDate not supplied

[Economic criminality. Problems of definition and lines of research].

After reviewing the many proposed definitions of economic criminality, which are now very numerous in specialized literature, and after considering the various critical attitudes assumed on this point by the most qualified experts on the subject, the Authors state that it is absolutely indispensable to establish an appropriate definition on which an aggreement can be reached. In fact, without such a definition it is impossible to deal with the object of interest and therefore to make any progress with the research, the legislation and the measures necessary for the prevention and repression of economic criminality. If this problem of economic criminality is discussed at the various national and international levels without the aforementioned definition, this is an indication that a popular intuition has been formed which is able to distinguish the object of interest. The most suitable lines of research are indicated in order to establish and clarify the elements of such an intuition which the Authors consider in a hypothetical light.

Commerce↗
PubMed1986

The variability of the circle of Willis: univariate and bivariate analysis.

The results are presented of a statistical analysis of the variability of the circle of Willis using univariate and bivariate methods. For this purpose 100 circles of Willis were available. From each circle 19 indexes of arterial size were determined, the basilar artery was measured in two places. Half the circumference was measured. This data yielded no evidence of differences between left- and right-sided vessels in the sample. An important source of variation is the general size of all vessels considered. When the data are cleared from this general size variation, correlation coefficients reveal interesting relations between the vessels. The posterior communicating arteries are strongly related to the ipsilateral carotid artery, whereas a strong inverse relationship exists with the basilar artery and the precommunicating part of the ipsilateral posterior cerebral artery. These relationships can be understood from the expected patterns of the blood flow in these vessels. Similar relationships can be found in the anterior part of the circle of Willis and in the vertebro-basilar junction. In a different manner, based on previous haemodynamic studies, the relation between blood flow and vessel size within the circle of Willis can be demonstrated by relating the ratios of the sizes of afferent and efferent arteries to the sizes of the posterior communicating arteries, an "intuitive" model. The supposed correlations of the outcome of this "intuitive" model with the size of the communicating arteries appeared to by highly significant. It is concluded that the variations of the circle of Willis are related to the individual variations of the blood flow in this arterial network.

Analysis of Variance↗
PubMed1980

Visual communication in the psychoanalytic situation.

The relationship between verbal and visual aspects of the analytic proceedings shows them blended integrally in the experiences of both patient and analyst and in contributing to the insights derived during the treatment. Areas in which the admixture of the verbal and visual occur are delineated. Awareness of the visual aspects gives substance to the operations of empathy, intuition, acting out, working through, etc. Some typical features of visual 'language" are noted and related to the analytic situation. As such they can be translated with the use of logic and consciousness on the analyst's part, not mere random eruptions of intuition. The original significance of dreams as a royal road to the unconscious is confirmed-but we also find in them insights to be derived with higher mental processes. Finally, dyadic aspects of the formation and aims of dreams during analysis are pointed out, with important implications for the analyst's own self-supervision of his techniques and 'real personality" and their effects upon the patient. how remarkable that Dora's dreams, all too belatedly teaching Freud about their transference implications, still have so much more to communicate that derives from his capacity to record faithfully observations he was not yet ready to explain.

Adolescent↗
PubMedDate not supplied

The personal knowledge of family physicians for their patients.

The physician-patient relationship has always been of interest to family physicians. This paper describes a component of the physician-patient relationship in family medicine, originally identified by Michael Balint, that operates parallel to and in conjunction with the biopsychosocial model: the family physician's personal knowledge of patients. The physician's personal knowledge of patients is a personal information network about particular patients who the physician has cared for over a series of encounters spanning several years. It is a detailed portrait painted with layers of fact, intuition, and experience and is comprised of a mix of clinical art, science, psychodynamics, and ethics. It may be factual, intuitive, or contain components of countertransference; it differs from Kleinman's concept of explanatory model in that it belongs to the physician and is employed for the benefit of the patient. It is neither paternalistic nor static. The family physician's personal knowledge for his or her patients is a seldom-measured but common component of the process of making medical, ethical, and pragmatic patient care decisions. The presence of this knowledge and its skillful use may mark one difference between novice and seasoned clinicians. Qualitative methods are most appropriate for exploring the breadth and depth of this concept, while quantitative methods are useful for studying its implications for clinical decision making and quality of care in family practice.

Aged↗
PubMed1994

Subsumption principles underlying medical concept systems and their formal reconstruction.

Conventional medical concept systems represent generic concept relations by hierarchical coding principles. Often, these coding principles constrain the concept system and reduce the potential for automatical derivation of subsumption. Formal reconstruction of medical concept systems is an approach that bases on the conceptual representation of meanings and that allows for the application of formal criteria for subsumption. Those criteria must reflect intuitive principles of subordination which are underlying conventional medical concept systems. Particularly these are: The subordinate concept results (1) from adding a specializing criterion to the superordinate concept, (2) from refining the primary category, or a criterion of the superordinate concept, by a concept that is less general, (3) from adding a partitive criterion to a criterion of the superordinate, (4) from refining a criterion by a concept that is less comprehensive, and finally (5) from coordinating the superordinate concept, or one of its criteria. This paper introduces a formalism called BERNWARD that aims at the formal reconstruction of medical concept systems according to these intuitive principles. The automatical derivation of hierarchical relations is primarily supported by explicit generic and explicit partititive hierarchies of concepts, secondly, by two formal criteria that base on the structure of concept descriptions and explicit hierarchical relations between their elements, namely: formal subsumption and part-sensitive subsumption. Formal subsumption takes only generic relations into account, part-sensitive subsumption additionally regards partive relations between criteria. This approach seems to be flexible enough to cope with unforeseeable effects of partitive criteria on subsumption.

Subject Headings↗
PubMed1993

Theory-based correlations and their role in children's concepts.

Recent accounts of conceptual development have emphasized the important role intuitive theories play in concept formation; however, it is still not clear exactly how these theories exert their influence. We present evidence that elementary school age children use theories to link together specific features associated with individual concepts. The results of our first experiment indicate that theory-based correlations play a prominent role in typicality judgments and in decisions about category membership. In a second experiment, we demonstrate that children's theories play an important role in determining which attributes will be considered most central to the concept. The results of these studies suggest that feature correlations can serve to link children's concepts with their intuitive theories of the world.

Child↗
PubMed1993

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.

Cognition↗
PubMed1996

Mexican-American and Anglo-American children's responsiveness to a theory-centered AIDS education program.

Third, fifth, and seventh graders, most of them Mexican-American, were exposed to an empirically based and culturally sensitive AIDS curriculum designed to replace their intuitive theories with a coherent, scientific account of the causal processes that lead from risk behavior to AIDS symptomatology. Compared to students in control classes, experimental students knew more about AIDS risk factors and AIDS generally, displayed more conceptual understanding of the causes of AIDS and flu, and were more willing to interact with people who have AIDS (although not less worried about AIDS) at posttest and typically at follow-up 10-11 months later. The findings point to the potential value of adopting an intuitive theories approach in assessing and modifying children's concepts of health and illness and suggest, contrary to Piagetian formulations, that even relatively young children can, with appropriate instruction, grasp scientific theories of disease.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Assessment of health status in peritoneal dialysis patients: a potential outcome measure.

OBJECTIVES: To determine the feasibility and practicality of measuring general health status (GHS) in an outpatient peritoneal dialysis population. To determine whether GSH correlated intuitively with biochemical, socio-demographic and co-morbidity measurements. DESIGN: The Medical Outcomes Study 20-item short form was administered on a voluntary basis in the outpatient setting. Demographic and current biochemical data were extracted from the medical record. The effects of the socio-demographic, biochemical and physiologic variables on the six subscales of GHS generated by the questionnaire were estimated using multivariate linear regression analysis resulting in the development of six separate models. SETTING: Peritoneal dialysis program of a University Hospital. PATIENTS: Sixty stable patients on home peritoneal dialysis completed the GHS questionnaire during regularly scheduled outpatient visits. Ages ranged from 13 to 81 years. The study group included 14 diabetics (23%). RESULTS: Administering the questionnaire caused no logistical difficulties in the outpatient setting. Regression models for predicting GHS were both significant and intuitively correct. The presence of co-morbidities such as diabetes mellitus (p = 0.002; Social Subscale) and peripheral vascular disease (p = 0.016: General Health Subscale) had the most significant negative impact on GHS. An increased length of time on dialysis was associated with a higher GHS (p = 0.002; Physical Subscale). CONCLUSION: General Health Status questionnaires can be readily administered to peritoneal dialysis patients in the outpatient setting. They have face validity as a measurement of wellness and functioning. The longitudinal use of such instruments in conjunction with clinical and laboratory findings may identify both medical and non-medical factors impacting on our peritoneal dialysis population.

Adolescent↗
PubMed1996

[From empirical 'dietetics' to rational dietetics].

From the outset, the terms 'dietetics' and 'diet' applied in their general acceptance to all the measures, whether or not alimentary, that can provide optimal living conditions for both the healthy and the diseased. In that meaning they are synonymous with hygiene or way of life. In their more restricted acceptance, which will be used henceforth, the terms apply to the choice of food and beverages which promotes or restores health of normal and sick people. In its most restricted meaning, the term 'diet' is confined to the nutrition of the sick, consisting either in a more or less drastic limitation of food intake, or in the prescription of specific foods. Due to the absence of scientific knowledge concerning the processes of life in general, and in particular concerning the physiology of the digestive system and the metabolism, the 'dietetic' rules and principles were governed until the middle of the nineteenth century by empiricism with a strong background of intuition, tradition, magic and religion. In his continuous struggle for life, man has been confronted with the dramatic consequences of the ingestion of toxic and spoiled food. Nausea, vomiting, diarrhea, cramps and eventually death have soon been linked with the ingestion of particular food, although the symptoms were attributed to supernatural forces. Intuitively and later by laws and prohibition, the use of certain foods was to be avoided or was forbidden. Moreover, with the development of cultures and civilizations food and food intake have acquired -besides their vital necessity-social and often magic-religious values which sometimes resulted in food taboos. In most civilizations these taboos have particulars in common: they are mainly directed against food of animal origin, more against meat than fish and particularly against red meat, which is being considered as symbol of strength and power and as endowed with exciting and stimulatory properties. The meat taboos are selective for some animals or parts of an animal, but what is allowed in some cultures is forbidden in others. More or less severe and long lasting abstinence from food or fasting was also self-inflicted or imposed to individuals or whole populations by religion, sometimes seemingly on hygienic grounds but in most cases without any logic reason. Since the earliest time, diets take-together with other dietetic measures-a prevailing place in the treatment of the sick and sickness. Most alimentary prescriptions are based on a more or less drastic restriction of food and - particularly in the seventeenth century with the iatrochemical school - also of fluids. The restrictions were not only quantitative, but also qualitative with restriction of meat consumption-particularly of red meat-and the prescription of more or less diluted decoctions of barley (infusions) or broth. The numerous works on 'dietetics' published-thanks to the development of printing-from the seventeenth on through the nineteenth century concern mainly the description of foodstuffs and beverages available at the time, and of the ways of preparing them. They also provide indications concerning the way these foodstuffs can improve health and/or list which of them can be prescribed or must be avoided in the treatment of the sick and of specific diseases. Some of these 'dietetical' prescriptions and maxims seem perfectly valid from a scientific and therapeutical point of view, - at least according to our actual knowledge - however, many are totally ineffective or are ridiculous and even dangerous. Except for the "dietetical" measures imposed by public hygiene or by religion to everyone, most of the dieteticotherapeutical prescriptions (food restrictions, clysters, purgation, bleeding) involved only the small fraction of the population that could afford medical assistance. The common people - the majority - could afford neither medical help, nor food abuse - except for an occasional feast - and had only access to a limited quantity and choi

Diet↗
PubMed1996

The empire of the ear: Freud's problem with music.

Freud's difficulty in appreciating music, even though he seems to have been one of Charcot's 'auditifs' and had given auditory imagery a central place in his psychology, is re-examined in the light of his dealings with various distinguished musicians, and with special reference to the musical career of 'Little Hans'. The author argues that Freud's exaggeration of his difficulty, combined with his ability to enjoy certain operas and his use of musical metaphors in the context of theory and therapy, confirms his own intuition of a conflict rather than a simple deficiency. This conflict is examined with reference to the theories of Eissler and of Vitz, and in the light of his own interest in classical Greek culture and in the nature of Art. Since opera was perhaps the only form of music that Freud could readily enjoy, the relation between words and melody in that genre is addressed. The significance for Freud of the specific works and passages that he mentions throughout his writings is examined in the light of some of his own theoretical concepts: (a) with special reference to 'oedipal' features, to the dynamics of 'eros' and 'thanatos', and to the balance between the 'primary' and 'secondary' processes in artistic creativity; and (b) as exemplified in his favourite operas 'The Marriage of Figaro', 'Don Giovanni', 'Carmen' and 'The Mastersingers'. The parts played, in his problem with music, by his envy of the artist's intuitive talent for seduction and by his own 'acoustic atrophy' are also considered. He is defended against the recent charge that, in order to avoid having to cede primacy to others on points of psychology, he deliberately misrepresented how much he knew about music.

Freudian Theory↗
PubMedDate not supplied

De-escalation in the management of aggression and violence.

De-escalation has historically been viewed by nurses as an intuitive process. This paper argues that de-escalation can be explained by reference to theory and an exposition of practice skills, and refutes the intuitive position by proposing that de-escalation can be understood as an interactive process with discrete identifiable components.

Humans↗