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PubMed1995

Creating a computer-aided intellectual environment for a consultative center of intensive care.

A consultative centre for intensive pediatrics (cip) is a center for rendering aid to children in urgent conditions who are hundreds kilometers from specialized help. Such aid is typically rendered by: 1)moving the patient to the another hospital, 2) the specialized team going out by plane, or 3) consulting the local physician by phone. The complexities of the cip dispatcher-consultation of the local physician entail a real-time system that provides a consultant with simultaneous operation with a computer and a local doctor over a phone. In 1987, a computer program, DINAR-1, was used. The core of this program was the scale of a patient's state severity "FHD-5.4" and essential elements of informative services: both a reference subsystem and one accumulating and analyzing data about cip activities, treated patients, and faults in the system of medical care. Two years of DINAR-usage showed the necessity of strengthening the decision support system for cip consultant. In 1989, a new program variant, DINAR-2, was completed. During the new variant's creation, we developed a model of decision making under conditions of information distortion (e.G., as a result of the subconscious influence of diagnostical hypotheses). This model was necessary for DINAR-2, because the most part of all information for decision making had subjective issue. Distinctions between levels of medical aid at the spot (in local hospitals) demanded the special assessment of a patient's state severity in order to adequately choose between tactical activities of the CIP. The severity of a patient's state original index depended on necessary therapy type; volume was developed. Special methodological interaction expedients between the user and the decision making system were verified in DINAR-2. The following improvements were also developed: subsystem of tuning on a definite area (1990); block of analytical final instructions on a patient's treatment (1991); visualization of introduced information (1991); determination of factors causing aggravation of a patient state (1992); and specialized subsystem of consultation of neonatals (1993). During the work, CIP got a new important function. CIP became a methodical center of the medical children aid. In keeping with this, a collection and analysis of information for regional health ministry became important part of DINAR-2. It is especially connected with touched discovery and analysis of medical defects. A system of child's death-rate analysis was especially created to make impartial decisions (1990). Expert subsystems had also an original continuation. This subsystem became a basis of the new system DINAR-created for the common pediatric physician who is attending a severely ill child. A principle addition to this system is a more complicated method of tactic solution choice. The technology of CIP supported by DINAR-systems had been bought by 35 different regions of the former USSR by 1994 (1989: one region; 1990: 2; 1991: 5; 1992: 10; 1993: 17 regions). The total population of all these regions is more than 59,000,000 people, and the total area is more than 11 million square kilometers. The main direction of DINAR's development is the creation of a regional computer network, allowing DINAR-to communicate with DINAR-in local hospitals. The first place for the usage of such a network is going to be the Big Urals Region. Big Ural consists of eight states. The total population of this territory is 28 million people and total area is 3.1 million square km. Computer networks will link eight regional CIPs to one another and the medical analytical center. The CIPs will have to be connected with 259 local hospitals. At present, the DINAR-2-CIP is installed in six states of the Big Ural, and DINAR-H is installed in four hospitals of the Sverdlovsk state.

Child↗
PubMed1992

[Experience in rendering medical care to infectious patients in Afghanistan].

For the first time it was Afghanistan where the 40th Army had faced with mass polyinfection morbidity which had a severe course and unfavourable outcome. In these conditions a new effective system of medical care to infectious patients was elaborated and applied. This system comprised a four-staged complex of medical and diagnostical measures. That made it possible to reduce the number of fatal cases by 16 times (from 0.49 to 0.03%) in 1983-1989. The total number of servicemen returned to active duty was brought up to 99.6%. The most important factors in this new system were the following: at prehospital stage--new methods in early definition of infectious patients, opportune diagnosis and emergency care; at hospital phase--new methods of triage, schemes of complex treatment for various nosological forms working principles of intensive therapy.

Afghanistan↗
PubMed2003

[An association (population attributable fraction) between smoking habit and mortality from all causes, cancer and lung cancer: NIPPON DATA80, 1980-1999. National Integrated Projects for Prospective Observation of Non-communicable Diseases and its Trend in the Aged].

OBJECTIVES: The authors examined the relationship and the population attributable fraction (PAF) between smoking habit and death from all causes, including cancer and lung cancer. METHODS: The baseline data were collected in the National Cardiovascular Survey in 1980 carried out for all household members aged 30 years or older in 300 districts, which were randomly selected throughout Japan. The number of participants in the survey was 10,546. The vital status was ascertained in 1999, and he calculated the adjusted relative risk of mortality and the PAF of mortality attributable to stopping smoking. RESULTS: A total of 9,629 subjects were available for the final analyses. There were 165,190 person-years of follow-up, and 2,011 deaths from all causes, including 579 deaths from cancer and 106 deaths from lung cancer. After adjustment for age and other cancer risk factors, smoking habit was associated with mortality from all causes, cancer and lung cancer. These associations had positive trends. The PAF (%) from all causes was 9.0 (male), 1.6 (female). The PAF (%) from cancer was 29.5 (male), 2.7 (female) and that from lung cancer was 42.9 (male), 7.1 (female). CONCLUSIONS: After adjustment for age and other cancer risk factors, smoking habit was associated with mortality from all causes, cancer and lung cancer. These associations had positive trends. The PAF (%) from all causes was 9.0 (male), 1.6 (female). The PAF (%) from cancer was 29.5 (male), 2.7 (female) and that from lung cancer was 42.9 (male), 7.1 (female).

Adult↗
PubMed2006

Endoscopic management of liver abscesses and cysts that communicate with intrahepatic bile ducts.

BACKGROUND AND STUDY AIMS: The formation of a communication between liver abscesses or cysts and intrahepatic bile ducts is an uncommon cause of significant bile leak. Surgical management of biliary fistulas is associated with high morbidity and mortality. We performed a prospective study of endoscopic management of this type of biliary fistula. PATIENTS AND METHODS: We studied 26 patients who had either liver abscesses or hepatic cysts that had ruptured into the intrahepatic bile ducts. The presence of a biliary fistula was suspected by jaundice and/or by the appearance of bile in percutaneous drainage effluent from a liver abscess and was confirmed by endoscopic retrograde cholangiopancreatography. Once the route of the fistula between the liver abscess or cyst and the intrahepatic bile duct had been defined by cholangiography, patients underwent treatment by sphincterotomy, and either biliary stenting or nasobiliary drainage. Nasobiliary drains or biliary stents (both 7 Fr) were placed according to standard techniques. Nasobiliary drains were removed when bile leakage stopped and closure of the fistula was confirmed by cholangiography; stents were removed after an interval of 4-6 weeks. RESULTS: Of a total of 525 patients with hepatic abscesses or cysts who were seen over a 5-year period, there were 26 patients who developed a demonstrable communication between liver abscesses (n = 20; 16 amebic, four pyogenic) or hydatid cysts (n = 6) and intrahepatic bile ducts (right intrahepatic bile ducts in 22 patients, left intrahepatic bile ducts in four patients). We performed either sphincterotomy with insertion of a nasobiliary drain (n = 20) or sphincterotomy with biliary stenting (n = 6). The fistulas healed in all patients after a mean time of 4 days (range 2-20 days) after endoscopic treatment. We were able to remove the nasobiliary drainage catheters and stents 6-34 days after their placement. CONCLUSIONS: In this case series, endoscopic therapy appears to be an effective mode of treatment for biliary fistulas complicating liver abscesses and cysts.

Adult↗
PubMed2000

Location and gross morphology of the nasopalatine duct in human adults.

OBJECTIVE: To characterize the nasal opening of the human nasopalatine duct (NPD; a major duct of the vomeronasal system used in animals for chemical communication) by identifying its location, categorizing variations in physical characteristics, and assessing frequency of detection. DESIGN: Two studies: (1) general study incorporating endoscopic examinations documented by videotapes and photographs, and an investigation of detection bias in terms of method of visualization and defining criteria for NPD identification; and (2) cadaver dissections examining NPD gross anatomy and proximity to the putative vomeronasal organ (VNO), the second major duct of the vomeronasal system. SETTING: Department of Otolaryngology, University of Chicago Hospitals, Chicago, Ill. SUBJECTS: A total of 125 university community volunteers, with a mean age of 23 years. RESULTS: (1) General study: NPD was located 1.9+/-0.02 cm (mean+/-SEM) dorsal to the columella nasi, and 0.2+/-0.01 cm above the nasal floor/septum junction, in both nostrils (90% bilateral), and was symmetrical in shape. An NPD was detected in 94% of 221 nostrils unobstructed in the region of interest. Fossa shapes were oval (57%), round (18%), spindle-shaped (18%), and tubular (7%). A small, round aperture was visualized in 30% of fossae. Among 3 observers, NPD detection frequency ranged from 94% to 40%, with the disparity due to inclusion of different defining characteristics. (2) Cadaver dissection study: bilateral nasal NPD fossae were found in every specimen probed to maximum approximate depth of 8 mm. No buccal pits associated with patent NPD were detected. Putative VNOs superior and just anterior to NPD fossae were detected in fewer than half the specimens. CONCLUSIONS: The nasal opening of the NPD is bilateral and symmetrical, located at the base of the nasal septum. Unusually contradictory anatomical descriptions in the human putative VNO literature may be attributable to inexact descriptions or misidentification of structures. The function of NPD remains controversial.

Adolescent↗
PubMed1999

Implementing and integrating computer-based activities into a problem-based gross anatomy curriculum.

A problem-based learning curriculum in gross anatomy was begun for a limited number of students to address unsuccessful methodology inherent in a traditional instructional approach. To eliminate some concerns associated with the laboratory component, computer-based instruction and other computer- related activities were actively integrated into the total instructional process. Prosections, directions, quizzes, images, and grades were provided in lab at table-side computer workstations, in the library, and on the web. Results were assessed through questionnaires in which students rated their learning experience according to a Likert-type scale. Success was measured by quantitative improvements in student perception. In this three-year study, observations and measurements have suggested increasingly positive student attitudes toward educational technology, for networks as a faster and more effective method of student/faculty communication, and in the utilization of computer-based instruction for greater flexibility and efficiency in learning. This allowed a rethinking of the structure and content of the curriculum by the faculty, which permitted reduced laboratory time, more small-group activity, and less reliance on staff.

Anatomy↗
PubMed2002

An outbreak of mumps in the metropolitan area of Walsall, UK.

OBJECTIVE: To describe the epidemiology of excessive mumps cases during the year 2000, within the metropolitan area of Walsall, UK; to assess the impact of the mumps outbreak on morbidity; and to inform future communicable disease control strategy. METHODS: Demographic records, school attendance, uptake of the measles-mumps-rubella (MMR) vaccine, and mumps-associated admission to hospital, were reviewed for all Walsall residents diagnosed and notified with mumps during the year 2000. RESULTS: There were 200 mumps notifications in 2000 (76.6 per 100,000), representing the highest incidence in England. Only 91 of the notified cases were salivary antibody positive for mumps IgM, and 32 were negative, although 77 were not tested. Since 1990, annual totals have never previously exceeded 20. Over 90% of patients were <20 years old, with a peak age group of 10-14 years; 88% attended schools located within Walsall. The pattern of spread suggested that the outbreak proceeded through schools from north to south in the more deprived western half of the metropolitan area. Most cases (136, 68%) had received one (99, 49.5%) or two (37, 18.5%) doses of MMR vaccine; cases > or =20 years old had never received MMR. Six cases (aged 4-14 years) were admitted to hospital, all with a successful outcome, including one male with meningitis and one female with pancreatitis. Current uptake of the MMR vaccine at 24 months has dropped to below 90% in recent years, as in most parts of the UK. CONCLUSIONS: Future mumps outbreaks in schools, and among older age groups, can be predicted, since most older children and young adults have received only one dose of MMR vaccine or no vaccination at all. Primary vaccine failure is well described in mumps, and cases during outbreaks can include recipients of two MMR vaccine doses. It was fortunate that no severe morbidity was associated with this outbreak (prior to MMR, two to four mumps deaths occurred annually in England and Wales). Measures to restore the uptake of MMR to the previous levels of above 90-95% will be necessary to reduce the risk of the mumps virus circulating within communities. Older children are susceptible, and it may be advisable to ensure second-dose MMR uptake while they are still at or when they leave school, or when they enter college, university or the military.

Adolescent↗
PubMed2003

A cost study of new media supported near oral anticoagulant treatment follow-up.

OBJECTIVE: In this study we sought to develop a comparative cost evaluation between conventional and new media, e.g. web, mobile communication technology and digital television, and near patient testing supported anticoagulant (ac) treatment follow-up in a primary health care setting. METHOD: The comparison was done for two patient groups, self-care and home-care patients, on oral ac treatment in the primary health care centre of the rural and sparsely populated municipality of Ikaalinen. In practise case analysis was used to develop cost functions from collected economic data, which were analysed to determine the break-even point in total cost between conventional and new media supported follow-up for the two patient groups. RESULTS: In the home-care setting the break-even point is 14 patients; in the self-care setting new media supported follow-up is always more cost-effective. CONCLUSION: The results illustrate that the use of new media and near patient testing in ac treatment follow-up brings about an economic benefit even with a small number of patients in the Ikaalinen setting. However, the sensitivity of break-even to perturbations in the individual costs of the used economic models remains high. Still, when the economic benefits are considered together with the clinical and practical benefits shown to result from self-testing, self-management and use of new media technologies the new service models can be said to provide noticeable benefits both in terms of quality of care and economics in our specific setting.

Administration, Oral↗
PubMedDate not supplied

Visual pedagogy in dentistry for children with autism.

The aim of the present study is to present and evaluate a model based on visual pedagogy for the introduction of dentistry to preschool children with autism. The model is based on the knowledge that it is easier for these children to communicate via pictures than via words. A book has been produced with distinct color-prints describing every step when visiting the dentist. The project has been designed in cooperation with the multi-professional team involved with the children. A total of sixteen children with autism participated in the project. Evaluation was done after 1.5 years. The ability of the children to cooperate is compared with that of sixteen children with autism of the same ages who were not treated with this method. The capacity of the children in the project to cooperate during dental treatment is superior to that of the control-children. Visual pedagogy is a way of introducing dentistry to children with autism.

Autistic Disorder↗
PubMed1999

A Double-Blind, Placebo-Controlled Trial of Secretin for the Treatment of Autistic Disorder.

OBJECTIVE: This study examines the efficacy of intravenous porcine secretin for the treatment of autism. METHODS: Using a randomized, double-blind, placebo-controlled crossover design, 20 subjects with autistic disorder received either a secretin or placebo infusion at baseline and the other substance at week 4. Subjects were given the Autism Diagnostic Interview-Revised, the Autism Diagnostic Observation Schedule-Generic (ADOS-G), and other pertinent developmental measures at baseline and at weeks 4 and 8 to assess drug effects. RESULTS: For the primary efficacy analysis, change of ADOS-G social-communication total score from week 0 to week 4, no statistically significant difference was obtained between placebo (-1.0 +/- 2.4) and secretin groups (-0.7 +/- 1.4; t 0.34, df 18, P less than.74). No significant differences were obtained for the other measures, including when all 20 subjects were compared by paired t-test from baseline to 4 weeks after secretin infusion. CONCLUSION: There was no evidence for efficacy of secretin in this preliminary randomized controlled trial. These data were collected as part of a multicenter study with the University of California-Irvine and the University of Utah.

Journal Article↗
PubMed2003

Gender analyses of nursing home residents with multiple sclerosis.

OBJECTIVE: To present gender comparisons of residents with multiple sclerosis (MS) at admission to nursing facilities, including demographic characteristics, health measures, and treatments. METHODS: We analyzed 13,998 admission assessments in the Minimum Data Set for residents with MS recorded between June 23, 1998 and December 31, 2000. RESULTS: Although both male and female residents with MS tended to have severe disability, there were significant gender differences in measures of activities of daily living (ADL) dependency and disability, with males slightly more likely to exhibit total ADL dependence and greater loss of voluntary movement. Females with MS tended to have significantly better cognitive performance and better communication abilities than males with MS. There were significant gender differences in pain symptoms among residents, with one-third of females and one-fifth of males experiencing daily pain. Depression was the most common comorbidity among residents with MS, with females significantly more likely to have this diagnosis. Although females with MS were slightly more likely to have depression or anxiety disorder, males with MS were slightly more likely to receive mental health services. CONCLUSIONS: These analyses demonstrate that many nursing facilities need to improve pain management and mental health care provided to residents with MS, especially to females.

Activities of Daily Living↗
PubMedDate not supplied

Survey of behavior management teaching in predoctoral pediatric dentistry programs.

PURPOSE: The purpose of this study was to survey directors of predoctoral pediatric dentistry programs regarding the teaching of behavior management techniques. METHODS: Surveys were mailed to all 56 dental schools in the United States. Follow-up mailings were sent to nonrespondents. The survey contained items on program demographics and the program's teaching of communicative and pharmacologic techniques. Information was also obtained on informed consent and parental presence in the operatory. RESULTS: Surveys were returned by 48 schools. Two schools declined to respond because they had not yet accepted or graduated students. The final response rate was 89%. The mean (+/-SD) percentage of total didactic time devoted to behavior management was 12% (+/-6). Communicative techniques were taught as "acceptable" by 96% to 100% of programs, with the exception of the hand-over-mouth exercise (HOME). HOME was taught as "unacceptable" by 62% of programs. Active and passive immobilization of sedated and nonsedated children was taught as "acceptable" by 69% to 85% of programs. Sixty-seven percent to 98% of programs taught that pharmacologic techniques (nitrous oxide, conscious sedation, general anesthesia) are "acceptable." There was little evidence that the teaching of behavior management techniques had changed over the previous 5 years, nor that they were likely to change in the near future. Parental presence in the operatory was common for some procedures, particularly among younger children. CONCLUSIONS: Predoctoral programs teach as acceptable communicative and pharmacologic management techniques, with the exception of HOME. Predoctoral program directors report they are not likely to increase the amount of curricular time devoted to behavior management in the near future.

Anesthesia, Dental↗
PubMed1992

A comparison of case retrieval times: film versus picture archiving and communications systems.

One of the advantages that a picture archiving and communications system (PACS) is supposed to provide over a film-based operation is improved performance in retrieving images. Although it seems self-evident that this should be so, this experiment was intended to verify this and to provide some time comparisons for the two methods. The experiment consisted of randomly selecting ultrasound and computed tomography cases and determining how long it took to retrieve files at a PACS workstation or in person from the file room. To simulate actual retrieval volumes, a total of 40 cases from current to 6 months old, 20 cases from the past year, and 10 cases more than 1 year old was selected. Results indicate that PACS retrieval can indeed be faster than file room retrieval. However, the difference is less for recent cases than for older cases. For cases 6 or fewer months old, the workstation retrieval was approximately 2.5 minutes faster per case than the film file room. This time difference increased markedly when extended to the 1-year and older-than-1-year groups. This report details the results of this study and provides information about the reliability of the two archives.

Filing↗
PubMed2002

[New international networks in radiology graduate and continuing education: www.eurorad.org--a EAR Project for online publication of radiological data].

Eurorad (www.eurorad.org) is a joint project of EAR and has support of 27 national and 8 subspeciality radiology societies. Eurorad is the first noncommercial radiological publication that is exclusively based on the internet as a communication line with all steps of submission, reviewing and publication being performed online. Eurorad wants to build up a huge and exhaustive case file of diagnostic and interventional radiology. Like all scientific publications, Eurorad bases on an editor in chief and 13 section editors who are responsible for organizing each section of Eurorad. Each section has a number of peer reviewer with an overall total of more than 100. For submission and publication, all cases are structured in the same manner with case report, method and discussion. For the time being, Eurorad hosts 779 cases, of whom 346 are free available on the net. The actual rejection rate is 4.5%, other cases are under review.

Curriculum↗
PubMed2002

Nurses' perceptions of discharge planning in acute health care: a case study in one British teaching hospital.

AIM OF THE STUDY: To provide an in-depth understanding of nurses' perceptions of the hospital discharge process in a London teaching hospital. BACKGROUND: Discharging patients from hospital is a key component of the nurse's role in acute health care settings. It is remarkable that despite government legislation and research, which stretches back over 20 years in both Europe and North America, discharge planning remains problematic. Furthermore, it is an activity that requires collaboration between health and social care agencies. In the United Kingdom there is a new emphasis and incentive on managing acute hospital beds, which in turn results in shorter stays in hospital. In London, discharge planners face additional problems because of social, economic and environmental factors. METHOD: Using a case study design, 19 nurses were interviewed using the critical incident approach to obtain their perceptions of the discharge process. Direct observation was conducted to record interactions between nurses and health care professionals in multidisciplinary teams. In total 14 meetings were attended in elder care and orthopaedics and 7 in acute medicine. FINDINGS: Aspects of the discharge process were often ignored or neglected and assessments were rarely co-ordinated. The nursing ward handover was regarded as a process that hindered communication. Lack of time was reported to be the biggest barrier that affected interprofessional working and hence the co-ordination of assessments. CONCLUSION: The findings have important implications for nurses, managers and educational establishments. It is essential that social and medical diagnoses run parallel and that accurate information is collated and communicated within the multidisciplinary team. Further research into the impact of time pressures on communication, interprofessional working and the discharge process is needed.

Attitude of Health Personnel↗
PubMed2000

Alcoholism in the emergency department: an epidemiologic study.

OBJECTIVE: To describe the epidemiology of alcoholism in ED patients. METHODS: Over a two-month period, every adult patient brought by ambulance to the ED of a large municipal hospital was prospectively enrolled by questionnaire. Data collected included demographics, previous ED use, triage complaint-related diagnoses, hospital admission rates, and ethanol levels (if determined). The CAGE alcoholism questions were administered to all patients by trained assistants. The only exclusion criterion was the inability to communicate while in the ED. A chi-square analysis was used to compare categorical variables. RESULTS: A total of 2,658 patients were enrolled in the study; 226 were unable to respond to the CAGE questions. Five hundred eighty-eight of the remaining 2,432 patients (24%) were defined as being alcoholic by an affirmative response to at least two of the CAGE questions. All four questions were answered affirmatively by 17% of the total patients. Alcoholic patients were more likely to be male (88% vs 60%), unemployed (87% vs 71%), undomiciled (46% vs 20%), polysubstance users (52% vs 25%), and tobacco users (77% vs 41%), and to have had an ED visit in the previous six months (51% vs 35%) (p < 0.001 for all tests). Ethanol levels ranged from zero to 573 mg/dL. Whereas no positive response to a single CAGE question was predictive of a final diagnosis of alcoholism, a blood ethanol level more than 300 mg/dL predicted an affirmative response to at least two CAGE questions in 97% of cases. CONCLUSIONS: Alcoholism should be presumed to be present in a substantial number of patients who present to urban EDs by ambulance.

Adult↗
PubMed1998

Meeting the challenge of managed care through clinical pathways for bariatric surgery.

BACKGROUND: The 1990s will bring sweeping changes in managed care and capitation. Health care providers are continually searching for new ways to improve the quality of patient-care outcomes in the obese. Improving clinical care by promoting the use of processes that have been proved to yield optimal outcomes has become a powerful strategy for measuring the value of services provided. METHODS: To address this cost/quality paradox, an optimal care path (OCP) was developed as a guideline for all patients undergoing gastric bypass or laparoscopic adjustable gastric banding. A transdisciplinary team developed the OCP, preprinted orders, discharge home instruction sheet, and daily guidelines for patients. All patients were provided with OCPs from July 1995 to September 1997. RESULTS: Length of stay decreased from 6.5 days to 5.4 days (16.9%); the average total charges decreased 17.6%, or $2,683; the percentage of wound infections decreased; and communication between, and collaboration of, interdisciplinary team members increased across the continuum of care. CONCLUSIONS: The study suggests that the use of OCP does not impair quality of care and can produce significant cost savings to a health care facility.

Critical Pathways↗
PubMed1992

Digital archive center: implementation for a radiology department.

OBJECTIVE: In this article, we describe the implementation of a digital archive center for a radiology department in a 700-bed teaching hospital. MATERIALS AND METHODS: The archive center consists of two identical archive systems, each comprising five components: an archive server, a data-base server, an optical disk library, a stand-alone optical disk drive, and a communication network. An image management system controls the image traffic from acquisition devices to display stations. A fault-tolerant mechanism was built into the archive center to achieve a 100% uptime. RESULTS: The center has been in operation for over 6 months. We have not experienced a single total system failure during this period. It currently archives all digital images from three MR units and four CT scanners and selected images from three computed radiographic systems and two laser film digitizers. The center archives between 1.5 and 2.0 gigabytes of images per workday. CONCLUSION: With its built-in fault-tolerant mechanism, we believe that the implemented archive center is very reliable and is suitable for a radiology department to archive its digital images.

Hospital Bed Capacity, 500 and over↗