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PubMed2006

Short communication: Strengthening sub-national communicable disease surveillance in a remote Pacific Island country by adapting a successful African outbreak surveillance model.

Successful communicable disease surveillance depends on effective bidirectional information flow between clinicians at the periphery and communicable disease control units at regional, national and global levels. Resource-poor countries often struggle to establish and maintain the crucial link with the periphery. A simple syndrome-based outbreak surveillance system initially developed and evaluated in Mpumalanga Province, South Africa was adapted for the Pacific island nation of Tuvalu. Eight syndromes were identified for surveillance: acute flaccid paralysis (poliomyelitis), profuse watery diarrhoea (cholera), diarrhoea outbreak, dysentery outbreak, febrile disease with abdominal symptoms and headache (typhoid), febrile disease with generalized non-blistering rash (measles), febrile disease with intense headache and/or neck stiffness with or without haemorrhagic rash (meningococcal meningitis), and outbreaks of other febrile diseases of unknown origin. A user-oriented manual, the Tuvalu Outbreak Manual (http://www.wepi.org/books/tom/), was developed to support introduction of the surveillance system. Nurses working in seven outer island clinics and the hospital outpatient department on the main island rapidly report suspected outbreaks and submit weekly zero-reports to the central communicable disease control unit. An evaluation of the system after 12 months indicated that the Outbreak Manual was regarded as very useful by clinic nurses, and there was early evidence of improved surveillance and response to the disease syndromes under surveillance.

Cholera↗
PubMed1988

Addressing concurrent review coding problems.

The coding policy/procedure manual, as one would expect, requires that constant attention be given to updating and clarification of coding practices and issues, but the rewards make the time spent well worth it. Coding consistency is achieved (although this is not an easy feat when dealing with a greater number of coders) and the coding supervisor is able to readily refer personnel to the coding policies/procedures and reduce communication time. The coders no longer waste time digging through stacks of journals, publications, and memos trying to find information pertaining to their present coding dilemma. The manual provides a mobile, organized filing device for staff members who spend the majority of their days on the nursing units performing concurrent coding. Last, but not least, the manual provides for a comprehensive, timely and historical coding resource base which works nicely for those times when an undesirable Professional Review Organization DRG modification needs to be appealed by the facility.

Abstracting and Indexing↗
PubMed2005

Using cognitive task analysis to facilitate the integration of decision support systems into the neonatal intensive care unit.

OBJECTIVE: New medical systems may be rejected by staff because they do not integrate with local practice. An expert system, FLORENCE, is being developed to help staff in a neonatal intensive care unit (NICU) make decisions about ventilator settings when treating babies with respiratory distress syndrome. For FLORENCE to succeed it must be clinically useful and acceptable to staff in the context of local work practices. The aim of this work was to identify those contextual factors that would affect FLORENCE's success. METHODS: A cognitive task analysis (CTA) of the NICU was performed. First, work context analysis was used to identify how work is performed in the NICU. Second, the critical decision method (CDM) was used to analyse how staff make decisions about changing the ventilator settings. Third, naturalistic observation of staff's use of the ventilator was performed. RESULTS: A. The work context analysis identified the NICU's hierarchical communication structure and the importance of numerous types of record in communication. B. It also identified important ergonomic and practical requirements for designing the displays and positioning the computer. C. The CDM interviews suggested instances where problems can arise if the data used by FLORENCE, which is automatically read, is not manually verified. D. Observation showed that most alarms cleared automatically. When FLORENCE raises an alarm, staff will normally be required to intervene and make a clinical judgement, even if the ventilator settings are not subsequently changed. CONCLUSIONS: FLORENCE must not undermine the NICU's hierarchical communication channels (A). The re-design of working practices to incorporate FLORENCE, reinforced through its user interface, must ensure that expert help is called on when appropriate (A). The procedures adopted with FLORENCE should ensure that the data the advice is based upon is valid (C). For example, FLORENCE could prompt staff to manually verify the data before implementing any suggested changes. FLORENCE's audible alarm should be clearly distinguishable from other NICU alarms (D); new procedures should be established to ensure that FLORENCE alarms receive attention (D), and false alarms from FLORENCE should be minimised (B, D). FLORENCE should always provide the data and reasoning underpinning its advice (A, C, D). The methods used in the CTA identified several contextual issues that could affect FLORENCE's acceptance. These issues, which extend beyond FLORENCE's capability to suggest changes to the ventilator settings, are being addressed in the design of the user interface and plans for FLORENCE's subsequent deployment.

Cues↗
PubMed2006

Providing patients with reviews of evidence about COPD treatments: a controlled trial of outcomes.

Studies in many countries have identified gaps between what is known from research evidence and what is done in clinical practice. Merely making research evidence available to practitioners does not cause much change in their behaviour, and researchers are now looking for more effective ways to improve the implementation of evidence. We report outcomes at three months of a parallel group trial of an evidence based patient manual designed to improve implementation of evidence by the patient's doctors. The patient manual was produced with extensive patient and professional input. It contained summaries of the evidence for treatments used in COPD (chronic obstructive pulmonary disease) and prompted discussion of evidence with doctors. Participants in the intervention arm of the trial (n = 125) were supplied with the manual and participants in the control arm (n = 124) were supplied with a pamphlet about COPD produced by the Australian Lung Foundation. The primary outcome measure (rates of current influenza vaccination and bone density testing) was an indicator of evidence based management of COPD. Secondary outcomes were quality of life (mastery component), satisfaction with information, communication with usual doctor, and anxiety. At three months no pattern of benefit in outcome measures was found for either group. Process measures showed high levels of personal use of the manual but progression to conversations with doctors for fewer than half of participants, and little treatment change. The findings highlight the difficulties of promoting changes in health behaviour and show that even when all stakeholders are consulted success is not guaranteed. Further research is required to identify those patients most likely to use manuals such as the one reported here, and how to make patient mediated interventions more effective for a greater proportion of the target population.

Aged↗
PubMed1991

Frequency and distribution of Alzheimer's disease in Europe: a collaborative study of 1980-1990 prevalence findings. The EURODEM-Prevalence Research Group.

We reanalyzed and compared current prevalence estimates of Alzheimer's disease in Europe. Studies characterized as follows qualified for comparison: dementia defined by the Diagnostic and Statistical Manual for Mental Disorders, 3rd edition, or equivalent criteria; Alzheimer's disease diagnosed by the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association or equivalent criteria; case-finding through direct individual examination; appropriate sample size; and inclusion of institutionalized persons. Of the 23 European surveys of dementia considered, six fulfilled the inclusion criteria. When age and sex were considered, there were no major geographic differences in the prevalence of Alzheimer's disease across Europe. Overall European prevalence (per 100 population) for the age groups 30 to 59, 60 to 69, 70 to 79, and 80 to 89 years was, respectively, 0.02, 0.3, 3.2, and 10.8. Prevalence increased exponentially with advancing age and, in some populations, was consistently higher in women. Prevalence remained stable over 15 years in one study.

Adult↗
PubMed1992

PC-based application programs in large health care systems.

Public health care agencies lack the infrastructure to meet the increasing operational demands on them, but there is little comparative data on alternative operational structures and systems from which to formulate remedies. Improved information management systems could help address both the workload and the gathering of critically needed data. PC-based database and application programs (PC-APs) that communicate with the mainframe are proposed as a methodology for filling the information-processing gap between mainframe computing and manual information systems. We also propose a model for systematic study of information management systems in clinical settings which can be used to evaluate other aspects of clinical program operations as well. A pilot study demonstrating these methodologies suggests that this is a fruitful approach to assessing ambulatory care operations and that PC-APs can improve administrative and clinical functions and enhance FTE productivity at lower overall cost.

Ambulatory Care Information Systems↗
PubMed2005

Is "relationship fear" unique to Japan? Symptom factors and patient clusters of social anxiety disorder among the Japanese clinical population.

BACKGROUND: There have been only a limited number of cross-cultural studies of social anxiety disorder (SAD), especially as diagnosed with modern operationalized diagnostic criteria and as measured with recently developed assessment instruments. We examined the symptomatological structure and clinical subtypes of patients with DSM-IV SAD among the Japanese clinical population. METHODS: We performed confirmatory and exploratory factor analyses of the joint Social Interaction Anxiety Scale and Social Phobia Scale from 149 psychiatric patients diagnosed with SAD. Based on the derived symptom factors, we further ran cluster analysis to identify patient subgroups. RESULTS: Factor analyses revealed three factors which were named "scrutiny fears", "conversation fears" and "relationship fears". The first two appeared common to Western clinical populations but the third appeared unique to the Japanese. Cluster analysis based on these three factor scores yielded three subgroups, which were externally validated and which overall corresponded with mild, moderate and pervasive subtypes of social phobia. LIMITATIONS: Both factor analysis and cluster analysis employed in the present study are exploratory in nature. Further empirical examination in different settings and cultures is necessary to provide definitive answers. CONCLUSIONS: It is suggested that we may need three symptom subscales and three subtypes in order to better account for cultural variations in the presentation of SAD.

Adolescent↗
PubMed1998

Accurate prediction of histologically confirmed Alzheimer's disease and the differential diagnosis of dementia: the use of NINCDS-ADRDA and DSM-III-R criteria, SPECT, X-ray CT, and Apo E4 in medial temporal lobe dementias. Oxford Project to Investigate Memory and Aging.

In a prospective study of more than 200 cases of dementia and 119 controls, annual technetium-99m-hexamethyl-propylene amineoxime (99mTC-HMPAO) single-photon emission computed tomography (SPECT) and annual medial temporal lobe (MTL) oriented X-ray computed tomography (CT) have been used to evaluate the diagnostic potential of functional and structural neuroimaging in the differential diagnosis of dementia. Some subjects have had up to 7 annual evaluations. So far, of 151 who have died, 143 (95%) have come to necropsy. Histology is known for 118, of whom 80 had Alzheimer's disease (AD), 24 had other "non-AD" dementias, and 14 controls with no cognitive deficit in life also had no significant central nervous system pathology. To compare the findings in the dementias with the profile of structural and functional imaging in the cognitively normal elderly, scan data from 105 living, elderly controls without cognitive deficit have also been included in the analysis. All clinical diagnoses were according to National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) criteria, and all histopathological diagnoses according to the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) criteria. Early data from this cohort have suggested that the combination of both MTL atrophy seen on CT with parietotemporal hypoperfusion on SPECT may predict the pathology of AD. The diagnostic sensitivity, specificity, accuracy, and positive and negative predictive values of the NINCDS-ADRDA and DSM-III-R criteria could be assessed in this cohort against the gold standard of histopathology. The diagnostic potential of CT evidence of MTL atrophy alone, SPECT evidence of parietotemporal hypoperfusion alone, and the combination of both of these scan changes in the same individual could then be compared against the diagnostic accuracy of clinical operational criteria in the pathologically confirmed cases. Furthermore, all of these modalities could be compared with the diagnostic accuracy of apolipoprotein E4 (Apo E4) genotyping to predict AD in the histopathologically confirmed cohort. In this population, NINCDS "probable-AD" was 100% specific, 49% sensitive, and 66% accurate; "possible-AD" was only 61% specific, but 93% sensitive and 77% accurate; and the combination of both "probable-AD" and "possible-AD" was 61% specific, 96% sensitive, and 85% accurate. DSM-III-R criteria were 51% sensitive, 97% specific, and 66% accurate. In the same cases and including the 105 living, elderly controls, the diagnostic accuracy of the Oxford Project to Investigate Memory and Aging (OPTIMA) scanning criteria showed CT alone to be 85% sensitive, 78% specific, and 80% accurate; SPECT alone had 89% sensitivity, 80% specificity, and 83% accuracy; and the combination of the two was 80% sensitive, 93% specific, and 88% accurate. The Apo E4 genotype was 74% sensitive but yielded 40% false positives in the histologically confirmed series. The diagnostic accuracy afforded by this method of CT and SPECT used alone is better than that of any established clinical criteria and reveals that the combination of MTL atrophy and parietotemporal hypoperfusion is common in AD, much less common in other dementias, and rare in normal controls. In the NINCDS-ADRDA criteria "possible-AD" cases, the combination of CT and SPECT findings alone were better in all diagnostic indices than the presence of Apo E4 alone in predicting AD. The frequent occurrence of MTL atrophy in AD and also in other "non-AD" dementias later in the course of the disease suggests the concept of medial temporal lobe dementia. This could explain some of the overlap of clinical profiles in the dementias, particularly as the dementia progresses, making clinical differential diagnosis difficult. In this context, the use of SPECT can significantl

Adult↗
PubMed2002

Quality and outcomes of heart failure care in older adults: role of multidisciplinary disease-management programs.

PURPOSE: To determine whether the management of heart failure by specialized multidisciplinary heart failure disease-management programs was associated with improved outcomes. BACKGROUND: The advent of angiotensin-converting enzyme inhibitors, beta-blockers, and spironolactone has revolutionized the management of heart failure. Randomized double-blind studies have demonstrated survival benefits of these drugs in heart failure patients. Nevertheless, in spite of these advances, heart failure continues to be a syndrome of poor outcomes.1-4 There is also evidence that a significant portion of heart failure patients does not receive this evidence-based therapy that reduces morbidity and mortality.5-7 Various disease-management programs have been proposed and tested to improve the quality of heart failure care. Most of these programs are specialized multidisciplinary heart failure clinics lead by cardiologists or heart failure specialists and conducted by nurses or nurse practitioners. Similar to the Department of Veterans Affairs (VA) multidisciplinary geriatric assessment clinics, these clinics also use many other services, including pharmacists, dietitians, physical therapists, and social workers. Some of these programs also have an affiliated home health service. Several observation studies, using mostly pre- and postcomparison designs, have demonstrated the effectiveness of these programs in the process of care, resource use, healthcare costs, and clinical outcomes in patients with heart failure.8 Risk of hospitalization was reduced by 50% to 85% in six of the studies.8 Subsequently, several randomized trials were conducted to determine the effectiveness of these programs. The purpose of this systematic review was to determine the effectiveness of these programs on mortality and hospitalization rates of heart failure patients. METHODS: Published articles on human randomized trials involving specialized heart failure disease-management programs in all languages were searched using Medline from 1966 to 1999 and other online databases using the following terms and Medical Subject Headings: case management (exp); comprehensive health care (exp); disease management (exp); health services research (exp); home care services (exp); clinical protocols (exp); patient care planning (exp); quality of health care (exp); nurse led clinics; special clinics; and heart failure, congestive (exp). In addition, a manual search of the bibliographies of searched articles was performed to identify articles otherwise missed in the above search. Personal communications were made with three authors to obtain further data on their studies. Using a data abstraction tool, two of the investigators separately abstracted data from the selected articles. Data from the selected studies were combined using the DerSimonian and Laird random effects model and the Mantel-Haenszel-Peto fixed effects model. Meta-Analyst 0.998 software (J. Lau, New England Medical Center, Boston, MA) was used to determine risk ratios (RRs) with 95% confidence intervals (CIs) of mortality and hospitalization for patients receiving care through these specialized programs compared with those receiving usual care. The Cochran Q test was used to test heterogeneity among the studies, and sensitivity analyses were performed to examine the effect of various covariates, such as duration of intervention, and other characteristics of the disease-management programs. RESULTS: The original search resulted in 416 published articles, of which 35 met preliminary selection criteria. Of these, 11 were randomized trials and were selected for the meta-analysis. Studies that were not randomized trials, did not involve heart failure patients or disease-management programs, or had missing outcomes were excluded. Of the 11 studies selected, nine involved specialized follow-up using multidisciplinary teams and the remaining two involved follow-up by primary care physicians and telephone. These studies involved 1,937 heart failure patients with a mean age of 74. The follow-up period ranged from no follorom no follow-up (one study) to 1 year (one study). Patients receiving care from specialized heart failure disease-management programs had a 13% lower risk of hospitalization than those receiving usual care (summary RR = 0.87; 95% CI = 0.79 -0.96), but the Cochran Q test demonstrated significant heterogeneity among the studies (P =.003). Subgroup analysis of the nine studies using specialized follow-up by a multidisciplinary team showed similar results (summary RR = 0.77, 95% CI = 0.68-0.86; test of heterogeneity, P>.50). Seven of the nine studies did not show any significant association between intervention and reduced hospitalization, but the two studies that used follow up by primary care physicians and telephone failed to show any significant reduction in hospitalization (summary RR = 0.94, 95% CI = 0.75-1.19). In fact, one of the studies demonstrated a higher risk of hospitalization for patients receiving intervention (RR = 1.26, 95% CI = 1.04-1.52). Of the 11 studies, only six reported mortality as an outcome. None of these studies found any association between intervention and mortality (summary RR = 1.15, 95% CI = 0.96-1.37; test of heterogeneity, P>.15). Five of the studies used quality of life or functional status as outcomes, and, of them, only one demonstrated significant positive association. The results of the sensitivity analyses were negative for any significant association with duration of intervention or follow-up or year of study. Eight studies performed cost analyses and seven demonstrated cost-effectiveness of the intervention. CONCLUSIONS: The authors concluded that specialized disease-management programs were cost-effective, and heart failure patients cared for by these programs were more likely to undergo fewer hospitalizations, but the study did not provide any conclusive association between these programs and quality of care or mortality. The authors recommend that disease-management programs involve patient education and specialized follow-up by a multidisciplinary team including home health care.

Comment↗
PubMed2005

The neuropathology of autism: a review.

Presented is a review of recent progress in the understanding of autism based on investigations of donated human brain tissue. Autism is a pervasive developmental disorder by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria, manifesting by age 3 and characterized by impairments in social interaction and communication, as well as restricted, repetitive, stereotyped patterns of behavior. Based on reported neuropathologic findings, these characteristic behaviors are clinical manifestations of both pre- and postnatal alterations. This review summarizes the current data obtained from postmortem brain studies in the areas of stereology, neurotransmitter systems/synaptic processes, molecular mechanisms, and neuroimmunology. In addition, we discuss current research strategies designed to facilitate translational research and maximize the yield of precious resources (e.g. the Autism Tissue Program), highlight barriers to research, and consider future trends.

Animals↗
PubMed2005

The distribution and development of handedness for manual gestures in captive chimpanzees (Pan troglodytes).

This article describes the distribution and development of handedness for manual gestures in captive chimpanzees. Data on handedness for unimanual gestures were collected in a sample of 227 captive chimpanzees. Handedness for these gestures was compared with handedness for three other measures of hand use: tool use, reaching, and coordinated bimanual actions. Chimpanzees were significantly more right-handed for gestures than for all other measures of hand use. Hand use for simple reaching at 3 to 4 years of age predicted hand use for gestures 10 years later. Use of the right hand for gestures was significantly higher when gestures were accompanied by a vocalization than when they were not. The collective results suggest that left-hemisphere specialization for language may have evolved initially from asymmetries in manual gestures in the common ancestor of chimpanzees and humans, rather than from hand use associated with other, non-communicative motor actions, including tool use and coordinated bimanual actions, as has been previously suggested in the literature.

Age Factors↗
PubMed2004

Preventing ectopic pregnancies: how often does transperitoneal transmigration of sperm occur in effecting human pregnancy?

OBJECTIVE: Transperitoneal transmigration of sperm constitutes the mechanism by which ectopic pregnancies occur in unilaterally obstructed fallopian tubes. This study was undertaken to determine how often sperm transmigrate across the peritoneal cavity to effect human pregnancy. DESIGN: In women with non-communicating rudimentary uterine horn pregnancies, the ratio of total uterine horn pregnancies to prior contralateral hemi-uterine pregnancies was calculated to infer the overall transperitoneal sperm transmigration rate. The prior parity frequency distribution was also determined to calculate the best-fit per-pregnancy probability of attaining a rudimentary horn pregnancy with each subsequent gestation using maximum likelihood estimation. SETTING: 20th century. SAMPLE: Non-communicating rudimentary uterine horn pregnancies reported from 40 countries. METHODS: Two hundred and seventy-two cases were identified using manual and computerised searches of Index Medicus, Excerpta Medica, the Index-Catalogue of the Library of the Surgeon-General's Office and standard reference tracing. MAIN OUTCOME MEASURES: The ratio of total prior non-rudimentary uterine horn pregnancies to rudimentary uterine horn pregnancies and the frequency distribution of prior maternal parities. RESULTS: Prior to the incident 272 uterine horn pregnancies, the number of observed pregnancies was 292 (ratio = 0.93), implying an aggregate sperm transmigration rate of 0.48. Using the prior parity frequency distribution, the best-fit probability of attaining a rudimentary horn gestation per-pregnancy was 0.51 (95% CI 0.48-0.56). CONCLUSIONS: Intraperitoneal sperm transmigration occurs approximately half the time in effecting spontaneous human pregnancies. To minimise the risk of ectopic tubal pregnancy in woman with unilaterally damaged fallopian tubes, salpingectomy should be the preferred surgical treatment, rather than attempting tubal salvage and repair.

Adult↗
PubMed2002

Psychometric properties of the Stroke Impairment Assessment Set (SIAS).

OBJECTIVE: To review the psychometric properties of the Stroke Impairment Assessment Set (SAS), which was developed in 1990 as a comprehensive instrument to assess stroke impairment. METHOD: Articles related to the SIAS were retrieved from the MEDLINE and the Folia Centro Japonica. RESULTS: Thirty-five articles were retrieved and analyzed. 1) Scale quality: Rasch analysis demonstrated the unidimensionality of the SIAS. Factor analysis produced factors corresponding to the 6 SIAS subscales. 2) Interrater reliability: The weighted kappas were high except for the unaffected side quadriceps item for which the score distribution was skewed. 3) Concurrent validity: Significant correlations were found between a) SIAS motor items and the Motricity Index or the Brunnstrom stage, b) SIAS lower extremity scores and the Functional Independence Measure (FIMSM) locomotion scores, c) trunk scores and abdominal manual muscle testing, d) visuospatial scores and line bisection and copying task scores, and e) speech scores and the FIMSM communication scores. 4) Predictive validity: Three studies attempting to predict discharge functional status demonstrated that adding the SIAS as one of the predictors enhanced the predictive power 5) Responsiveness: The SIAS was more responsive to changes than the Motricity Index, the Brunnstrom stage, or the National Institutes of Health Stroke Scale. CONCLUSION: The SIAS is a useful measure of stroke impairment with well-established psychometric properties.

Cerebrovascular Disorders↗
PubMed2004

Alleviating stuttering with pharmacological interventions.

Stuttering is a speech disorder characterised by frequent prolongations, repetitions or blocks of spoken sounds and/or syllables. Stuttering is very common and is classified by the Diagnostic and Statistical Manual of Mental Disorders -- Fourth Edition (DSM-IV) as an Axis I disorder. In spite of this, stuttering treatment is sporadically addressed by a practicing physician, especially in the US. Much has recently been learned of the neurophysiological basis of this disorder, which has provided insight into novel treatment strategies, thus helping to guide the practising clinician. Stuttering is likely to be associated, at least in part, to dopamine hyperactivity in the brain. Novel dopamine antagonists such as risperidone and olanzapine, have recently been shown to improve the symptoms of stuttering providing a strong foundation for physicians to more effectively treat this disorder.

Benzodiazepines↗
PubMed1997

Accurate prediction of histologically confirmed Alzheimer's disease and the differential diagnosis of dementia: the use of NINCDS-ADRDA and DSM-III-R criteria, SPECT, X-ray CT, and APO E4 medial temporal lobe dementias. The Oxford Project to Investigate Memory and Aging.

In a prospective study of more than 200 cases of dementia and 119 controls, annual technetium-99m-hexamethyl-propylene amineoxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) and annual medial temporal lobe (MTL) oriented X-ray computed tomography (CT) have been used to evaluate the diagnostic potential of functional and structural neuroimaging in the differential diagnosis of dementia. Some subjects have had up to 7 annual evaluations. So far, of 151 who have died, 143 (95%) have come to necropsy. Histology is known for 118, of whom 80 had Alzheimer's disease (AD), 24 had other "non-AD" dementias, and 14 controls with no cognitive deficit in life also had no significant central nervous system pathology. To compare the findings in the dementias with the profile of structural and functional imaging in the cognitively normal elderly, scan data from 105 living, elderly controls without cognitive deficit have also been included in the analysis. All clinical diagnoses were according to National Institute of Neurological and Communicable Disease and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) criteria, and all histopathological diagnoses according to the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) criteria. Early data from this cohort have suggested that the combination of both MTL atrophy seen on CT with parietotemporal hypoperfusion on SPECT may predict the pathology of AD. The diagnostic sensitivity, specificity, accuracy, and positive and negative predictive values of the NINCDS-ADRDA and DSM-III-R criteria could be assessed in this cohort against the gold standard of histopathology. The diagnostic potential of CT evidence of MTL atrophy alone, SPECT evidence of parietotemporal hypoperfusion alone, and the combination of both of these scan changes in the same individual could then be compared against the diagnostic accuracy of clinical operational criteria in the pathologically confirmed cases. Furthermore, all of these modalities could be compared with the diagnostic accuracy of apolipoprotein E4 (Apo E4) genotyping to predict AD in the histopathologically confirmed cohort. In this population, NINCDS "probable-AD" was 100% specific, 49% sensitive, and 66% accurate; "possible-AD" was only 61% specific, but 93% sensitive and 77% accurate; and the combination of both "probable-AD" and "possible-AD" was 61% specific, 96% sensitive, and 85% accurate. DSM-III-R criteria were 51% sensitive, 97% specific, and 66% accurate. In the same cases and including the 105 living, elderly controls, the diagnostic accuracy of the Oxford Project to Investigate Memory and Aging (OPTIMA) scanning criteria showed CT alone to be 85% sensitive, 78% specific, and 80% accurate; SPECT alone had 89% sensitivity, 80% specificity, and 83% accuracy; and the combination of the two was 80% sensitive, 93% specific, and 88% accurate. The Apo E4 genotype was 74% sensitive but yielded 40% false positives in the histologically confirmed series. The diagnostic accuracy afforded by this method of CT and SPECT used alone is better than that of any established clinical criteria and reveals that the combination of MTL atrophy and parietotemporal hypoperfusion is common in AD, much less common in other dementias, and rare in normal controls. In the NINCDS-ADRDA criteria "possible-AD" cases, the combination of CT and SPECT findings alone were better in all diagnostic indices than the presence of Apo E4 alone in predicting AD. The frequent occurrence of MTL atrophy in AD and also in other "non-AD" dementias later in the course of the disease suggests the concept of medial temporal lobe dementia. This could explain some of the overlap of clinical profiles in the dementias, particularly as the dementia progresses, making clinical differential diagnosis difficult. In this context, the use of SPECT can significantly e

Aged↗
PubMed1993

Hospital mainframe computer documentation of pharmacist interventions.

The hospital mainframe computer pharmacist intervention documentation system described has successfully facilitated the recording, communication, analysis, and reporting of interventions at our hospital. It has proven to be time efficient, accessible, and user-friendly from the standpoint of both the pharmacist and administrator. The advantages of this system greatly outweigh manual documentation and justify the initial time investment in its design and development. In the future, it is hoped that the system can have even broader impact. Intervention/recommendations documented can be made accessible to medical and nursing staff, and as such further increase interdepartmental communication. As pharmacists embrace the pharmaceutical care mandate, documenting interventions in patient care will continue to grow in importance. Complete documentation is essential if pharmacists are to assume responsibility for patient outcomes. With time being an ever-increasing premium, and with economic and human resources dwindling, an efficient and effective means of recording and tracking pharmacist interventions will become imperative for survival in the fiscally challenged health care arena. Documentation of pharmacist intervention using a hospital mainframe computer at UIH has proven both efficient and effective.

Chicago↗