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PubMed2000

Clinical and practical requirements of online software for anesthesia documentation an experience report.

The aim of this paper is the presentation of a new version of the anesthesia documentation software, NarkoData, that has been used in routine clinical work in our department as part of an anesthesia information management system (AIMS) since 1995. The performance of this software is presented along with requirements for future development of such a system. The originally used version, NarkoData 3.0, is an online anesthesia documentation software established by the software company ProLogic GmbH. It was primarily developed as a disk-based system for the MacOS operating system (Apple Computer Inc.). Based on our routine experience with the system, a catalogue of requirements was developed that concentrated on improvement in the sequence of work, administration and data management. In 1996, the concepts developed in our department, in close co-operation with medical personnel and the software company, led to a considerable enlargement of the program functions and the subsequent release of a new version of NarkoData. Since 1997, more than 20 000 anesthesia procedures have been recorded annually with this new version at 115 decentralized work stations at our university hospital.

Anesthesiology↗
PubMed2003

XML as standard for communicating in a document-based electronic patient record: a 3 years experiment.

During the past few years, the eXtensible Markup Language (XML) has progressively become a gold standard for accessing, representing and exchanging information, especially in the health care environment. This paper presents an implementation of the use of XML for the electronic patient record (EPR) and discusses more specifically its growing use in two areas of the EPR: first, as a format for the exchange of structured messages, and second, as a comprehensible way of representing patient documents. These statements rely on a 3 years experiment conducted at the Geneva University Hospital as part of its document-centered EPR.

Delivery of Health Care↗
PubMed2000

Early onset benign occipital susceptibility syndrome: video-EEG documentation of an illustrative case.

Early onset benign occipital susceptibility syndrome (EBOSS) is a recently delineated form of idiopathic childhood partial epilepsy, which is still not recognized by the International League Against Epilepsy as a distinct epileptic syndrome. It occurs with generally nocturnal, prolonged partial seizures, which can become a status epilepticus. The seizures are characterized by tonic eye deviation, vomiting, progressive impairment of consciousness, autonomic symptoms, frequent progression to hemiconvulsions or generalized tonic-clonic seizures. Age at onset is usually between 3 and 7 years, frequency is remarkably low (often a single seizure), and outcome is excellent. Interictal EEG shows occipital paroxysms with fixation-off sensitivity. We present the first video-EEG documentation of a typical case of EBOSS and discuss the clinical and EEG features of the case. The documentation is useful for a better definition of the syndrome and also permits a differential diagnosis with respect to other occipital forms of epilepsy and other sleep related paroxysmal disorders.

Age of Onset↗
PubMed2002

How animal embryo research led to the first documented human IVF.

Research studies using animal gametes led to the first documented human IVF in 1969. A key contribution was the development of a reliable culture medium for IVF of hamster oocytes, which was then used successfully with human gametes in the laboratory. This article describes how this was accomplished. Hamster IVF was obtained using a bicarbonate-buffered culture medium based on Tyrode's solution. A dose-response experiment showed that IVF in this species was highly dependent on the pH of the culture medium. At pH 7.2 or less, very few oocytes were penetrated and spermatozoa did not undergo acrosome reactions. Over the pH range 7.3-7.5, 40% of oocytes were fertilized in vitro, while at pH 7.6 or higher, more than 75% of oocytes were fertilized and most spermatozoa exhibited acrosome reactions. There was no apparent effect of pH on sperm motility. These experiments showed that in the hamster, fertilization in vitro is highly pH dependent, most likely through pH effects on the sperm acrosome reaction and sperm:zona binding. The data led to formulation of a culture medium, Tyrode-B, that consistently supported high levels of IVF of hamster oocytes. When this medium was used for human gametes, IVF was observed and documented for the first time. Spermatozoa penetrating through the zona pellucida and sperm components within the ooplasm were detected, and some oocytes exhibited two pronuclei. These observations suggested that human IVF might be useful for alleviation of infertility.

Animals↗
PubMedDate not supplied

ACNM essential documents: a midwife's suit of armor.

As the oldest professional midwifery organization in the United States, The American College of Nurse Midwives (ACNM) represents the profession of midwifery in the United States and sets standards for education, certification, and practice. The ACNM has generated and revised several critical documents that provide guidance for the scope of midwifery practice, individually and collectively. This article reviews essential ACNM documents and their role in supporting professional midwifery.

Credentialing↗
PubMedDate not supplied

JChemTidy: a tool for converting chemical Web document collections to an XHTML representation.

A robot-based procedure is described for traversing a collection of hyperlinked documents written in HTML and converting these to the XML-compliant and well-formed XHTML representation. Transcluded chemical content invoked using or HTML calls are converted to the XHTML recommended form. Additional attributes such as title or derived chemical attributes such as a SMILES descriptor are added to improve the indexing of the resulting document collection. Conformance tests for the popular Web browsers are reported.

Journal Article↗
PubMed1998

Recovered memory of childhood sexual trauma: a documented case from a longitudinal study.

A case of recovered memory of childhood trauma is reported with documented sexual trauma in early childhood, chronicled evidence of the absence of memory for traumatic experience over a period of time, and substantial evidence of 'spontaneous' recovery of memory. This account contains the first available prospective report of memory loss in a case in which there is both documented evidence of trauma and evidence of recovery of memory. The case emerged as part of a broadband, large-scale study of children followed closely from birth to adulthood which was not focused on memory for trauma. Prospective data gathered in a neutral research context, corroborated and supplemented by retrospective information, circumvent many limitations of previous retrospective accounts of recovered memories.

Adolescent↗
PubMed2004

The development of MML (Medical Markup Language) version 3.0 as a medical document exchange format for HL7 messages.

Medical Markup Language (MML), as a set of standards, has been developed over the last 8 years to allow the exchange of medical data between different medical information providers. MML Version 2.21 used XML as a metalanguage and was announced in 1999. In 2001, MML was updated to Version 2.3, which contained 12 modules. The latest version--Version 3.0--is based on the HL7 Clinical Document Architecture (CDA). During the development of this new version, the structure of MML Version 2.3 was analyzed, subdivided into several categories, and redefined so the information defined in MML could be described in HL7 CDA Level One. As a result of this development, it has become possible to exchange MML Version 3.0 medical documents via HL7 messages.

Medical Informatics Applications↗
PubMed2005

Forgery: 'fingerprinting' documents and packaging.

We have found that almost all paper documents, plastic cards and product packaging contain a unique physical identity code formed from microscopic imperfections in the surface. This covert 'fingerprint' is intrinsic and virtually impossible to modify controllably. It can be rapidly read using a low-cost portable laser scanner. Most forms of document and branded-product fraud could be rendered obsolete by use of this code.

Journal Article↗
PubMed2003

NHS Dentistry: Options for Change in context--a personal overview of a landmark document and what it could mean for the future of dental services.

The aims of this paper are to provide an impartial overview of the proposals and agenda for the future brought together in the NHS Dentistry: Options for Change document in the context of previous dental service delivery in primary care, and to start to explore what Options for Change could mean for the future of NHS dental services. Options has been described as perhaps the most radical and ground breaking opportunity for NHS dentistry to finally move forward after prolonged periods of stagnation and disharmony. The Options agenda has the potential to bring in a new style of NHS practice for dentistry, providing a way to finally get off the current 'treadmill' and to develop new NHS dental services where prevention is a priority and providing high quality dental treatment, tailored to the long term needs of the 21st century patient, is the driving aim. However, the difficulties on all sides of leaving behind decades of disputes and overcoming real access, workforce and funding issues must not be underestimated or dismissed. The report was prepared by a working group comprising representatives from the profession, of patient groups and various sections of the Department of Health in England which was brought together by the then Chief Dental Officer. The key themes and priorities for action identified in Options include: local commissioning and funding, methods of remuneration for general dental practitioners, prevention and an oral health assessment for patients, clinical pathways, information and communication technology, practice structure, development of the dental team and the patient experience. The document also contains comprehensive reports of the three Options for Change task groups making recommendations for: 1) a new deal for patients - national standards, 2) systems of delivery of dental care and 3) education, training and development of the dental team. Ways forward for delivering improved, modern, effective, preventive, patient-centred dental care have been identified. This potential can, however, only be realised if viable and sustainable agreements can be achieved to operationalise the best choices.

Critical Pathways↗
PubMed2006

International spinal research trust research strategy. III: A discussion document.

STUDY DESIGN: Discussion document. OBJECTIVES/METHODS: To review the Research Strategy of the International Spinal Research Trust (ISRT), which identifies key areas of basic and clinical research that are likely to be beneficial in developing potential treatments for spinal cord injury for funding. This strategy is intended to both guide the programme of research towards areas of priority and stimulate discussion of the different avenues of research. This latest document has been developed to take into account the scientific progress in the 6 years since publication of the previous Research Strategy. RESULTS/DISCUSSION: The latest scientific developments in research designed to repair the spinal cord and restore function following injury and how they might impact on spinal cord injury research are highlighted.

Biomedical Research↗
PubMed1997

A chart audit reviewing the prescription and administration trends of analgesia and the documentation of pain, after surgery.

The report of the joint working party of the Royal College of Surgeons of England, Pain after Surgery, raised many questions in relation to the way pain is managed after surgery. This report questioned many of the existing practices of pain control and highlighted the need for the development of regular pain assessment. The report raised questions regarding PRN (pro-re nata, as needed) prescribing and reinforced the importance of the role of the nurse. This study reviews the way pain is managed in this hospital with regard to analgesia prescribing and analgesia administration trends as well as the documentation of pain. The study was conducted by retrospective review of randomly selected patient charts. The results of this study conclude that documentation of pain following surgery is poor, and needs improvement. Existing prescription trends, in particular PRN prescribing, may be hindering both good practice and the pre-emptive administration of analgesia.

Adult↗
PubMed1999

Conservative management of documented neuroretinitis in cat scratch disease associated with Bartonella henselae infection.

BACKGROUND: Bartonella henselae has been identified as the causative agent of the neuroretinitis associated with cat scratch disease (CSD). Immunofluorescent antibody tests with good sensitivity and specificity are available to aid in diagnosis. Despite diagnostic advances, optimal management remains controversial. We present a case of documented B. henselae macular neuroretinitis managed without antibiotics and discuss antibiotic use in this condition. METHODS: We examined a young woman with macular neuroretinitis and established a diagnosis of CSD. Management consisted of a review of the literature, followed by educating her about the condition and close observation. We documented the course of her disease. RESULTS: We diagnosed neuroretinitis associated with B. henselae infection based on immunofluorescent antibody titres and clinical presentation. Our patient's neuroretinitis resolved promptly without antibiotic therapy. CONCLUSIONS: Macular neuroretinitis in CSD can be satisfactorily diagnosed with the use of fluorescent antibodies in the appropriate clinical setting. Optimal treatment for the disease has not been established and observation combined with patient education remains an appropriate option. The self-limited nature of the disease implies that treatment studies not using controls must be interpreted with great caution. Adverse drug reactions and other iatrogenic complications can be reduced by limiting antibiotic use in settings where a meaningful treatment benefit has not been established.

Adult↗
PubMed1998

Documentation of children's vaccination status in child care centres in Victoria.

OBJECTIVE: To assess the record-keeping of child care centres in Victoria with respect to children's vaccination status. METHODOLOGY: A random sample of 113 centres from a list of over 800 registered Victorian child care centres received a mailed questionnaire on characteristics and policies of the centre, including documentation of attending children's vaccination status. RESULTS: The response rate was 86.7%; more than 95% of centres had children under two in care. Only 85% of centres kept any record of children's immunisation status, with smaller centres and class 2 centres (occasional care centres) significantly less likely to keep records. Records were updated irregularly. Fewer than half of the centres studied kept a record of whether children had been vaccinated against Haemophilus influenzae type b. CONCLUSIONS: Despite the importance of documenting children's vaccination status, many child care centres have failed to develop adequate systems to record or update records of children's immunisation. This makes exclusion during outbreaks of a vaccine-preventable disease difficult. The ongoing process of accreditation may eventually improve performance, but both legislation and a better educational strategy to improve practice in this area are needed.

Child Day Care Centers↗
PubMed2003

[Violence by Psychiatric In-Patients of the BZK Gabersee - First Results of a Standardized Documentation]

After a cluster of severe assaults against our staff we performed a standardized documentation concerning aggressive behaviour of in-patients at the BZK Gabersee, a major District Hospital with a typical spectrum of psychiatric patients. From July 1996 to March 2001 23 037 patients were admitted and 1618 cases of aggressive behaviour were documented. About 75 % of the patients were males, more than 50 % were treated involuntarily. The aggressions were most frequently directed against the nursing staff, severe injuries occured very rarely. We tried to analyse triggers and the individual motivations of aggressive behaviour. Countermeasures were often aggressive as well (reinforced medication, restraint e. g.). The results are discussed in the context of the literature, approaches to cope with and to reduce aggressions are mentioned briefly.

Journal Article↗
PubMed2003

Documentation of brachial plexus compression (in the thoracic inlet) utilizing provocative neurosensory and muscular testing.

Diagnosis and documentation of brachial plexus compression in the thoracic inlet, "thoracic outlet syndrome", remains difficult because the syndrome complex overlaps that of patients with cervical disc disease, intrinsic shoulder pathology, and peripheral nerve compression. While traditional electrodiagnostic testing can identify cervical radiculopathy and the rare isolated lower trunk compression, it cannot identify brachial plexus compression in the thoracic inlet. In 2000, neurosensory testing with the Pressure-Specified Sensory Device (PSSD) was applied to this diagnostic dilemma, demonstrating a significant increase in the one-point static touch cutaneous pressure threshold between controls and patients, when the index finger (upper trunk) and little finger (lower trunk) were tested with the hands at rest and after provoking the plexus by elevating the hands above the head. In the present study, this approach has been extended to include two-point static touch thresholds with the PSSD, and pinch and grip strength (Digit-Grip). Sixteen controls (mean: 34.2, range: 11 to 48 years) were tested and the 99 percent upper confidence limit calculated for percent change after elevation of the hands for 3 min. Forty-one patients symptomatic for brachial plexus compression (mean: 41.0, range: 21 to 62 years) were tested. The clinical severity of the plexus compression was dichotomized as either "severe" or "not severe" judged by the Roos and Tinel sign. Results demonstrated that when five or more of the eight possible neurosensory and motor test results were > 99 percent normal confidence limit for change, this testing has a sensitivity of 82 percent, a specificity of 100 percent, and a positive predictive value of 100 percent for the diagnosis of clinically severe brachial plexus compression. Seventeen patients who were in the "severe" category prior to surgery, were tested before and after plexus neurolysis and anterior scalenectomy. All 17 patients were clinically improved and in 16 of these patients, postoperative neurosensory and motor testing returned to a normal pattern (no significant increase in thresholds with hand elevation). It is concluded that neurosensory (PSSD) and motor testing (Digit-Grip) can help in the diagnosis and documentation of brachial plexus compression.

Adolescent↗
PubMed2004

[Evidence-based hospital management considering data from the psychiatric basic documentation system].

OBJECTIVE: The study aimed to demonstrate how data from the psychiatric basic documentation system (DGPPN-BADO) are able to support the hospital management in making evidence-based decisions. METHODS: Data from 14 327 psychiatric in-patients in the years 1997, 1999 and 2001 were analysed. RESULTS: About 40 % of patients were admitted without any medical sending, 20 % were referred by a general practitioner and 10 % by a psychiatrist in private practice. Between 1997 and 2001 an increase of patients with affective disorders and personality disorders was found. Comparing 1999 to 2001, patients showed greater deficits in their psychosocial capability (measured with GAF) at admission, but also at discharge. Outpatient aftercare was recommended to more than 80 % of in-patients, about 50 % by a general practitioner and about 33 % by a psychiatrist in private practice. 10 % of patients were cared by the own outpatient clinic. CONCLUSIONS: Data from the psychiatric basic documentation system could be shown as being relevant for evidence-based hospital management ensuring an effective and efficient in-patient treatment.

Aftercare↗
PubMed1987

Prognosis of hypertension first documented during labor.

In order to assess the prognosis of hypertension first documented during labor, an inception cohort of all women with hypertension complicating pregnancy was assembled. In this cohort, even extreme elevations of blood pressure, regardless of the degree of proteinuria, were not associated with either maternal or fetal adverse outcomes. Therefore, some degree of hypertension during labor may be physiologic. Matched pairs analysis demonstrated that intravenous (IV) magnesium sulfate, administered to prevent seizures, was associated with an excess number of primary cesarean sections. Given the excellent prognoses in patients with good antepartum care in whom hypertension is first documented during labor, the need for any preventive measures, or for antihypertensive or anticonvulsant treatment, should be reconsidered.

Blood Pressure↗