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The laboratory as an aid to clinical diagnosis.

The clinician may use the clinical pathology laboratory as a valuable aid to diagnosis and management, for the assessment of response to treatment, and in preventive medicine programs. Each "link in the chain," that is, sample selection, collection, handling, analysis, result reporting, and interpretation must be carefully and efficiently managed, using an informed combination of art and science, to provide a useful endpoint. This general introduction precedes more specific and detailed articles.

Animals↗

Varieties of Helmholtz Machine.

The Helmholtz machine is a new unsupervised learning architecture that uses top-down connections to build probability density models of input and bottom-up connections to build inverses to those models. The wake-sleep learning algorithm for the machine involves just the purely local delta rule. This paper suggests a number of different varieties of Helmholtz machines, each with its own strengths and weaknesses, and relates them to cortical information processing. Copyright 1996 Elsevier Science Ltd.

Journal Article↗

Predicting the impact of new health technologies on average length of stay: development of a prediction framework.

OBJECTIVES: The aim of this study was to develop a framework to predict the impact of new health technologies on average length of hospital stay. METHODS: A literature search of EMBASE, MEDLINE, Web of Science, and the Health Management Information Consortium databases was conducted to identify papers that discuss the impact of new technology on length of stay or report the impact with a proposed mechanism of impact of specific technologies on length of stay. The mechanisms of impact were categorized into those relating to patients, the technology, or the organization of health care and clinical practice. RESULTS: New health technologies have a variable impact on length of stay. Technologies that lead to an increase in the proportion of sicker patients or increase the average age of patients remaining in the hospital lead to an increase in individual and average length of stay. Technologies that do not affect or improve the inpatient case mix, or reduce adverse effects and complications, or speed up the diagnostic or treatment process should lead to a reduction in individual length of stay and, if applied to all patients with the condition, will reduce average length of stay. CONCLUSIONS: The prediction framework we have developed will ensure that the characteristics of a new technology that may influence length of stay can be consistently taken into consideration by assessment agencies. It is recognized that the influence of technology on length of stay will change as a technology diffuses and that length of stay is highly sensitive to changes in admission policies and organization of care.

Biomedical Technology↗

Translation of clinical trials into clinical practice: use of results in formulating guidelines.

The "evidence base" for arrhythmology is enormous and highly variable in quality and relevance. Every day, more information becomes available from basic science, bedside research, randomized trials, structured registries, and clinical experience. It has become critically important to develop methods for collating and synthesizing all of these strands of evidence into a useful and applicable format. The guideline is an increasingly valuable tool for this purpose. Guidelines are constructed in a formal and approved manner such that the evidence is graded and combined to produce appropriately classified practical recommendations. Arrhythmology guidelines now must be funded, implemented, value tested, and regularly revised.

Arrhythmias, Cardiac↗

Alternatives models in carcinogenicity testing--a European perspective.

Transgenic mouse strains offer the prospect of significant benefits in the in vivo assessment of carcinogenic potential. The European Regulatory Authorities have been supportive of their inclusion as one of the second-test options in the International Conference on Harmonization of Technical Requirements for the Registration of Pharmaceuticals for Human use (ICH). However, there is a concern regarding premature systematic use of these models. At present, the information from the International Life Sciences Institute (ILSI) project suggests that the transgenic models under study are similarly sensitive to genotoxic pharmaceuticals. There are apparently some false negatives and false positives. For regulatory purposes, it is not yet possible to differentiate the models with respect to hazard identification and risk assessment. The evaluation of the models has reached an interesting but, at certain points, equivocal stage. Based on the weight of evidence gathered thus far, regulatory authorities cannot neglect the outcome of such studies but need to be cautious in their interpretation of data from such models, and the application in risk assessment procedures.

Animals↗

Two decades of "research-practice" encounters in the development of European therapeutic communities for substance abusers.

In 1981, a "research-practice" breakthrough was realized through the foundation of the European Federation of Therapeutic Communities (EFTC). Since its foundation EFTC regularly organized conferences and symposia. A few years later (in 1983), the European Workshop On Drug policy Oriented Research (EWODOR) was established at the Erasmus University in Rotterdam, including a special section devoted to the therapeutic community (TC). The authors examined the proceedings of all meetings organized by EFTC and EWODOR. The major topics presented throughout the last 20 years are highlighted in a chronological selection and these presentations largely focus on the challenges of the TC and the state of the art regarding scientific knowledge. In this overview only those authors who published articles in scientific journals indexed in the "Web of Science" (Institute for Scientific Information-ISI) were retained. Although research has never been the primary consideration in TCs, it played a far from negligible role in its development. Research findings prompted innovations and thus often provoked resistance, but on the other hand they functioned as a catalyst between the necessity of a belief system and the reality of society. The role of "grey" literature and the availability of information through the Internet will become more and more important in the communication between researchers and practitioners.

Communication↗

Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature.

The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.

Humans↗

Systematic review of the use and value of computer simulation modelling in population health and health care delivery.

BACKGROUND: The objective of the review was to evaluate the extent, quality and value of computer simulation modelling in population health and health care delivery. METHODS: A narrative systematic review was carried out of world literature from 1980 to 1999, searching Medline, INSPEC, Embase, HealthSTAR, Science Citation Index, CINAHL, MathSci, INFORMS Online and SIGLE databases, and researchers in the field were contacted. Papers were included if they contained a computer simulation model of individuals in a stochastic system and the topic or setting related to population health or health service delivery. RESULTS: A total of 182 papers met the inclusion criteria. Simulation modelling has been undertaken in a wide range of health care topic areas, including hospital scheduling and organization, communicable disease, screening, costs of illness and economic evaluation. However, the quality of published papers was variable and few reported on the outcomes of implementation of models, so that the value of modelling could not be assessed. CONCLUSION: Simulation modelling is a powerful method for modelling both small and large populations to inform policy makers in the provision of health care. It has been applied to a wide variety of health care problems. Although the number of modelling papers has grown substantially over recent years, further research is required to assess the value of modelling.

Communicable Disease Control↗

Despairing women and healing outcomes: a unitary appreciative nursing perspective.

The purpose of this article is to explicate unitary appreciative nursing and the emergence of healing outcomes associated with despairing women. Unitary appreciative nursing was derived from the science of unitary human beings, informed by the participatory worldview of cooperative inquiry, and shaped by the voices and perspectives of despairing women. It integrates 3 strands of responsiveness (unitary, appreciative, and participatory) to the chosen focus of practice. Healing outcomes for despairing women reflect a conceptualization of healing that involves realizing, knowing, and appreciating the wholeness of life, clarifying understandings of life patterning, and elucidating potentials and opportunities for the betterment of life-a journey toward human flourishing.

Adaptation, Psychological↗

10-year research update review: the epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology.

OBJECTIVE: To describe the growth of developmental epidemiology in the past decade and to illustrate it with examples of recent studies. METHOD: A review of publications on developmental epidemiology in the past 10 years and a discussion of some key examples. RESULTS: The authors describe how the interaction between developmental psychopathology and psychiatric epidemiology has produced developmental epidemiology, the study of patterns of distribution of psychiatric disorders in time as well as in space. They give two examples of the kinds of questions that developmental epidemiology can help to answer: (1) Is the prevalence of autism increasing? Does the use of vaccines explain the increase? (2) Is there an epidemic of child and adolescent depression? Finally, they describe two areas of science that are beginning to inform developmental epidemiology: molecular genetics and the use of biological measures of stress. CONCLUSIONS: While child and adolescent psychiatric epidemiology continues, as described in the first of these reviews, to address questions of prevalence and burden, it has also expanded into new areas of research in the past decade. In the next decade, longitudinal epidemiological data sets with their rich descriptive data on psychopathology and environmental risk over time and the potential to add biological measures will provide valuable resources for research into gene-environment correlations and interactions.

Adolescent↗

Nurses and the genomic revolution.

PURPOSE: To increase nurses' genetics and genomics literacy through a series of articles focused on genomic research discoveries and their importance for nursing education, practice, policy, and research. ORGANIZING FRAMEWORK: "Genomics for Health " is one of three themes, along with genomes to biology and genomes to society, emanating from applications of the Human Genome Project (HGP). METHODS: In this series of articles, nurse scientists who are experts in genetics and genomics sciences explain terminology, provide background information about the HGP, discuss clinical examples, and recommend changes in nursing practice, education, and research. CONCLUSIONS: The HGP has already led to major changes in clinical practice, research, education, and policy, and even more dramatic changes are predicted for people throughout the world. Mastering this information is necessary for nurses globally because genomic information will ultimately pervade all of health care.

Education, Nursing↗

Assessment of 'borderline' clinical competence using generalisability and decision studies in dental skills training.

INTRODUCTION: Generalisability coefficients are widely used as a measure of reliability in educational sciences. However, coefficients do not inform about how much individual and/or educational variance is needed for borderline competence. Probing depth measurements were used as an example to demonstrate the use of generalisability and decision studies in educational decision-making. METHOD: All six probing depths of seven elements of the first quadrant were assessed in a random crossed four-way 'elements' (7), 'probing depth' (6) 'observers' (7-8) and 'repetitions' design for both students (8) and faculty staff (7). Borderline competence was assessed in four decision study designs. RESULTS: In decision studies the generalisability coefficient varied from 0.31 to 0.88 for the first single and fourth repeated study design, respectively. The standard error of the measurement varied from 1.73 to 0.64 mm with a corresponding 95% confidence interval varying from 3 to 1 mm. CONCLUSION: Repeated measurement is not the most efficient way to improve educational decision-making. What is new to this approach is that we used the 95% confidence interval of the standard error of measurement as a measure for 'borderline competence' expressed in the unity of the measurement instrument. Correctly performing the procedure of probing depth assessment is of clinical and educational importance in deciding whether further treatment is necessary and whether students fail or pass their exams.

Analysis of Variance↗

Traffic calming for the prevention of road traffic injuries: systematic review and meta-analysis.

OBJECTIVE: To assess whether area-wide traffic calming schemes can reduce road crash related deaths and injuries. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials, Medline, EMBASE, Sociological Abstracts Science (and social science) citation index, National Technical Information service, Psychlit, Transport Research Information Service, International Road Research Documentation, and Transdoc, and web sites of road safety organisation were searched; experts were contacted, conference proceedings were handsearched, and relevant reference lists were checked. INCLUSION CRITERIA: Randomised controlled trials, and controlled before/after studies of area-wide traffic calming schemes designed to discourage and slow down through traffic on residential roads. METHODS: Data were collected on road user deaths, injuries, and traffic crashes. For each study rate ratios were calculated, the ratio of event rates before and after intervention in the traffic calmed area divided by the corresponding ratio of event rates in the control area, which were pooled to give an overall estimate using a random effects model. FINDINGS: Sixteen controlled before/after studies met our inclusion criteria. Eight studies reported the number of road user deaths: pooled rate ratio 0.63 (95% confidence interval (CI) 0.14 to 2.59). Sixteen studies reported the number of injuries (fatal and non-fatal): pooled rate ratio 0.89 (95% CI 0.80 to 1.00). All studies were in high income countries. CONCLUSION: Area-wide traffic calming in towns and cities has the potential to reduce road traffic injuries. However, further rigorous evaluations of this intervention are needed, especially in low and middle income countries.

Accidents, Traffic↗

[Quality management between science and competition].

The call for an increase in quality assurance becomes louder and louder. However, it is almost always understood as a more intensive monitoring of quality. The ideas of total quality management described in the ISO norms 9000-9004 gain ground only slowly. By defining quality indicators and developing practical guidelines or appropriate methods of quality management, science could provide the basis. Information processing can make essential contributions such as the profiles of the German perinatal surveys or the Swiss gynecological-obstetrical quality statistics developed by Hochuli et al., but the only way to a widely applied total quality management is quality-assuring activities and quality becoming factors of competition themselves.

Competitive Medical Plans↗

An examination of the reading performance of students with mild educational handicaps or learning disabilities.

Reading performance is a primary concern in both regular and special education. Reading is also the dominant medium through which educators conduct lessons, or students acquire information in subjects such as science and mathematics. Reading performance can be measured in a variety of ways. The present study examined the performance of students with mild educational handicaps (n = 28) or learning disabilities (n = 38) on a combination of norm-referenced and curriculum-based assessment (CBA) approaches that used science content. Overall, there were no significant differences between the samples on measures of word recognition, but significant differences favoring students with learning disabilities did occur in comprehension.

Achievement↗

Toxicological and environmental health information from the National Library of Medicine.

The National Library of Medicine's Toxicology and Environmental Health Information Program is the outgrowth of a 1966 document on "Handling of Toxicological Information," prepared by the Presidents Science Advisory Committee (National Library of Medicine, 1995). The Toxicology and Environmental Health Program is responsible for the creation and deployment of both bibliographic and factual files concerned with toxicology, carcinogenesis, developmental and reproductive effects of chemical substances, toxic chemical releases, and the medical and environmental behavior of chemical substances. The two main computer systems that provide bibliographic and factual data banks are Toxicology Data Network (TOXNET) and ELHILL. A number of the files found in the TOXNET system are built and maintained by other federal agencies such as the National Cancer Institute, the U.S. Environmental Protection Agency, the National Institute for Occupational Safety and Health.

Animals↗

Considering and enjoying tomorrow: global aging through a human becoming lens.

The aging of the world's population is a global issue of considerable importance to everyone, particularly nursing. Traditional developmental theories and the medical model have either neglected later life or highlighted the losses and deficits associated with advanced age, while more recent research on aging and the human becoming theory has provided a more balanced view. In this column, information from health and social sciences, the human becoming school of thought, and international political debates about aging are interwoven. Some attention is also given to the issues of the retirement and aging of the nurses.

Aged↗

Evaluation of recent pharmacy graduates' practice patterns, professional lifelong learning, pharmacy organization memberships, and salary.

OBJECTIVES: To document information on recent bachelor of science (B.S.) pharmacy graduates' practice patterns, professional lifelong learning (PLL) methods, pharmacy organization memberships, and salary. The association between advanced training and education on PLL methods, pharmacy organization membership, and salary are explored. DATA SOURCES: Pertinent literature was identified by MEDLINE searches (1966-1992). STUDY DESIGN: The results of a Fall 1991 survey of recent B.S. pharmacy graduates (n = 371) of the University of Wisconsin School of Pharmacy are reported (55 percent response rate). RESULTS: Hospital pharmacists devoted more time to PLL outside of work (18.00 +/- 17.89 h/mo) than community pharmacists (9.93 +/- 8.76 h/mo), t = 5.02, degrees of freedom (df) = 289, p < 0.001. Graduates who had completed an advanced degree program, residency, or fellowship (advanced degree/training [ADT]) spent more time in PLL (17.76 +/- 10.63 h/mo) compared with graduates who had only obtained a B.S. degree (10.63 +/- 8.56 h/mo), t = 3.80, df = 311, p < 0.001. Graduates who had ADT were more likely to belong to multiple pharmacy organizations (2.14 +/- 1.38 organizations) than hospital pharmacists (1.61 +/- 1.27 organizations) and community pharmacists (1.11 +/- 1.06 organizations). Of the pharmacists who graduated in 1989 and 1990 (one to two years postgraduation), 55 percent belonged to the American Pharmaceutical Association. This declined to 19 percent of the graduates from 1984 and 1985 (six to seven years postgraduation), a 62 percent decline in membership. Membership in the American Society of Hospital Pharmacists (ASHP) was held by 19 percent of graduates one to two years after graduation; and 34 percent of graduates belonged to ASHP six to seven years after graduation, an 81 percent increase. Graduates with ADT (compared with graduates with the B.S. degree only) showed the strongest correlation of membership affiliation, which was about equal with ASHP (phi = 0.32) and ACCP (phi = 0.33). Although pharmacists changed their individual pharmacy organization memberships during the first seven years after graduation, there was no evidence of a decline in overall interest in pharmacy organization membership. Pharmacists who had completed ADT had an annual mean salary of $51,112 +/- $10,012; those pharmacists who did not complete an ADT program had an annual mean salary of $46,440 +/- $7802, a difference of $4672 per year. Hospital pharmacists who had obtained ADT had an annual mean salary of $51,840 +/- $9765; B.S. pharmacists without ADT in hospital practice had an annual mean salary of $43,603 +/- $8192, a difference of $8237 per year. CONCLUSIONS: Pharmacists' PLL methods, organization memberships, and salaries varied significantly by their practice site and the completion of an ADT program.

Education, Pharmacy, Continuing↗