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MEDLEARN: a computer-assisted instruction (CAI) program for MEDLARS.

*MEDLEARN*, a second-generation computer-assisted instruction (CAI) program available (nationally) since October 1976, provides on-line training for MEDLINE, one of the National Library of Medicine's (NLM) Medical Literature Analysis and Retrieval System (MEDLARS) data base. *MEDLEARN* was developed as a joint effort between NLM and The George Washington University Medical Center. Using MEDLINE formats throughout, *MEDLEARN* combines tutorial dialogue, drill and practice, testing, and simulation. The program was designed in three tracks oriented to basic methods, advanced techniques, and new developments. Each topic is presented on two levels, permitting an alternate explanation for users encountering difficulty. *MEDLEARN*, coded in the computer language PILOT, was developed with a modular structure which promotes ease of writing and revision. A versatile control structure maximizes student control. Frequent interactions check immediate recall, general comprehension, and integration of knowledge. Two MEDLINE simulations are included, providing the student an opportunity to formulate and execute a search, have it evaluated, and then perform the search in MEDLINE. Commenting, news broadcasting, and monitoring (with permission only) capabilities are also available. Subjective field appraisals have been positive and NLM plans to expand *MEDLEARN* and produce similar programs for other data bases.

Computer-Assisted Instruction

Searching the MEDLARS file on NLM and BRS a comparative study.

A comparison of the MEDLARS data base as it is currently available from the National Library of Medicine and Bibliographic Retrieval Services (BRS), Inc., is presented in chart format, and some major capability differences between the two systems are highlighted. The information inlcuded justifies the dual availability of the data base in health sciences libraries. This paper is intended for searchers and others familiar with one or both systems. Administrators considering the acquisition of the BRS system may find the study useful.

MEDLARS

Corneal chromomycosis: double infection by Phialophora verrucosa (Medlar) and Cladosporium cladosporioides (Frescenius).

Phialophora verrucosa and Cladosporium cladosporioides were isolated from a corneal ulcer. The lesion had been previously treated with antivirals and steroids and did not respond to Pimaricin therapy or conjunctival flap. A penetrating keratoplasty was performed with good functional and optical results. Chromomycosis of the cornea is an unusual infection. This is the second case of Phialophora in Florida and the first case of Cladosporium infection.

Animals

MEDLINE searching and retrieval.

The development of MEDLINE searching philosophy and methodology is described. Searcher requirements and capabilities in moving from a batch-mode linear operation to the iterative searching and retrieval provided by the random access mode of MEDLARS II are discussed. A detailed tutorial on searching methodology for individual queries is covered. Elements of search formulation include requestor interview, query analysis, presearching, technics of selecting terminology, formulation logic, adapting indexing protocol in the search, on-line man-machine interface, and retrieval analysis. Similar searching technics are utilized in producing the two basic types of MEDLINE publications, recurring bibliographies (RBs) and literature searches (LSs). RBs are co-operative ventures between the NLM and professional organizations or other government agencies. LSs are NLM sponsored non-recurring bibliographies on a topic of current but also general interest to the medical community. All publications are produced through the retrieval and publication systems of MEDLARS II and graphic arts composing equipment. At the beginning of the 1978 publication year there were 27 RBs in routine production including Index Medicus. Through 1977, over 375 LSs had been produced.

MEDLARS

Primary journal selection using citations from an indexing service journal: a method and example from nursing literature.

Although serial literature is extremely important to a library collection, it is also the source of many problems. Specialty journal selection is difficult, particularly for the librarian of a small or intermediate-size library that is not in a position to develop or maintain an exhaustive or inclusive collection in a particular field or discipline. Steadily increasing journal costs and recent economic trends necessitate establishment or reexamination of a periodical collection policy. In this investigation, the technique used analyzes citations assigned to medical subject headings (MeSH) and subheadings by indexers who prepare the MEDLARS data base. Citations have been retrieved by exploiting the on-line nature of the MEDLARS data base. A four-year time period is used to identify specialty journals in the area of nursing. Results given include a separate rank-order listing arranged by decreasing frequency of productivity for each MeSH term searched. A composite listing is given for the 16,355 unique citations retrieved. The approach illustrated and data presented may be useful in establishing library policy for questions of periodical subscription and setting of priorities for binding and microform purchases. The purpose of the approach described is to predict collection demand with efficiency and economy.

Book Selection

The on-line user network: organization and working procedures.

The National Library of Medicine's on-line user community has grown from a small group of 25 institutions in October 1971 to more than 900 in January 1978. Management of the MEDLINE User Network, co-ordination of on-line data-bases, and provision of user support services are an important function of the MEDLARS Management Section (MMS). MMS is the point of contact for on-line users; a service desk is maintained to provide immediate assistance; and technical materials describing the various data-bases are prepared including the monthly NLM Technical Bulletin and the On-Line Services Reference Manual. Other management and support activities include the preparation of statistical reports; handling of on-line centre applications received from the Regional Medical Libraries; co-ordination of codes and passwords for users; and the distribution of off-line prints, off-searches, and tape copies of the data-bases. A monthly current awareness service is also provided. The working procedures for these support activities are described.

Fees and Charges

Syndrome--a changing concept.

Syndrome is one of the oldest terms in the medical vocabulary. Traditionally, the term has been used mainly as a designation for complex medical entities, such as multiple abnormalities, that are characterized by clusters of concurring symptoms, usually three or more. During the mid-twentieth century, the meaning and the use of the term were altered. First to take place was an attempt to eliminate physicians' names from syndrome nomenclature, resulting in a significant increase in the use of descriptive designations in proportion to eponyms. But the trend was counterbalanced by the creation of new classes of eponyms. Eponymous syndrome nomenclature now includes the names of literary characters, patients' surnames, subjects of famous paintings, famous persons, geographic locations, institutions, biblical figures, and mythological characters. This was followed by a relaxation in the scope of the definition of syndrome, wherein the term could also be used as a modifier indicating a special (sometimes unspecified) complexity of an already named pathological condition. Eventually syndrome changed from its original use as an exclusively medical term and came to mean anything unusual, abnormal, bizarre, or humorous, whether medical, social, behavioral, or cultural. This unrestrained use of the term is the principal cause of an enormous volume of the sometimes irrelevant syndrome literature cluttering databases in the MEDLARS system and of the deterioration of "SYNDROME" as a specific MeSH term and a useful search parameter.

Abstracting and Indexing

Secondary dyslipidemia. Inadvertent effects of drugs in clinical practice.

OBJECTIVE: To examine the available literature on commonly prescribed drugs and their effects on blood lipid and lipoprotein levels. DATA SOURCES: The review was based on searches of English-language articles from 1975 to 1990 by Medlars II and MEDLINE programs, the Index Medicus for 1980 to 1990, and references from identified articles. Relevant journals published within the last 6 months were also examined. STUDY SELECTION: More than 500 articles were identified for inclusion. Articles were selected on the basis of appropriateness of design to demonstrate significant results, determined by consensus when necessary. DATA EXTRACTION: Studies were classified according to type (observational or interventional), length of follow-up, and type of controls. Quanitative analysis of lipid, lipoprotein, and apoprotein changes induced by drugs was computed as the percentage of change observed during the course of the study (interventional) or compared with the controls at a given time (observational). DATA SYNTHESIS: Steroid hormones that have strong progestogenic and androgenic properties, retinoids, cyclosporine A, and phenothiazines are potentially atherogenic. Steroid hormones with dominant estrogenic properties, several anticonvulsants, biguanides, high-dose ketoconazole, and aminosalicylic acid are potentially antiatherogenic. Corticosteroids appear to elevate all the lipoprotein cholesterol levels. Oral estrogens, retinoids, and corticosteroids also can elevate triglyceride levels. Other drugs with questionable effects on lipoprotein metabolism are reviewed. CONCLUSION: Although the long-term implications of drug-induced lipoprotein changes are still undefined, physicians need to consider these effects in clinical practice.

Adrenal Cortex Hormones

Technetium bone scanning in the diagnosis of osteomyelitis: a meta-analysis of test performance. Diagnostic Technology Assessment Consortium.

PURPOSE: To determine the diagnostic performance of technetium bone scanning in the setting of possible osteomyelitis in the foot of a patient who has diabetes or other vasculopathy. DESIGN: Meta-analysis. Data identification and study selection: To be eligible for inclusion, a report must have used intravenous technetium-99m methylene diphosphonate or a similar agent in humans over the age of 16 years, must have addressed possible osteomyelitis of the lower extremity with ulcer or soft-tissue inflammation in the setting of diabetes, neuropathy, or vasculopathy, and must have allowed the generation of a two-by-two table. A structured search of the MEDLARS database found 296 possibly eligible reports; ten met all the inclusion criteria. DATA EXTRACTION AND SYNTHESIS: The reported sensitivity and specificity of each report were converted to their logistic transforms and a straight line was fitted by weighted least-squares regression. The line was then back-transformed to yield a summary receiver operating characteristic curve. The false-positive rate of the bone scan is at best in the range of 10 to 20%. This occurs at sensitivities between 70 and 80%. The studies with increased sensitivity also reported sizable increases in the false-positive rate ranging from 20 to over 90%. Even small increases in sensitivity have necessitated large sacrifices in specificity. Seven of the ten studies reported specificities under 70%. CONCLUSIONS: Published data defining the effectiveness of technetium bone scanning for the diagnosis of osteomyelitis in the impaired foot indicate relatively poor performance. In many clinical situations, the specificity of the bone scan will not be high enough to confirm the diagnosis of osteomyelitis.

False Positive Reactions

Hepatobiliary complications in patients with human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) infection has been associated with a number of hepatic and biliary tract disorders. Case reports, series of liver biopsies, and postmortem studies that examined the hepatobiliary system were retrieved with a MEDLARS search and form the basis of this review. The liver and biliary tract are frequently involved with opportunistic infections (most commonly mycobacteria and cytomegalovirus) and neoplasms (mainly Kaposi's sarcoma) in patients with HIV infection. The patients are often asymptomatic but may have elevated levels of serum liver enzymes. These abnormalities are nonspecific. Sulfa drugs, pentamidine, and ketoconazole are the medications used in HIV-related infections that are most likely to result in abnormalities on liver tests. Acalculous cholecystitis and sclerosing cholangitis also occur in HIV infection. Cytomegalovirus and Cryptosporidium are the organisms most commonly associated with these conditions. Imaging studies of the liver may detect parenchymal abnormalities and guide liver biopsy. The role of this procedure in the diagnosis of opportunistic infections and neoplasms is controversial because these lesions are generally disseminated at the time liver abnormalities are evident. A liver biopsy is best used when other less invasive procedures have failed to provide a diagnosis. Endoscopic retrograde cholangiopancreatography is a useful diagnostic procedure with therapeutic potential in patients with abdominal pain, fever, or an elevated serum alkaline phosphatase level.

Biliary Tract Diseases

Was the Dalkon Shield a safe and effective intrauterine device? The conflict between case-control and clinical trial study findings.

OBJECTIVE: To compare the findings of the case-control and cohort studies used to indict the Dalkon Shield (A.H. Robins Company, Inc., Richmond, VA) with the findings of the Dalkon Shield clinical trials. DATA IDENTIFICATION: All published reports on the Dalkon Shield were identified through MEDLARS system (United States National Library of Medicine) searches and by cross checking all references in these reports. The same approach was used to identify all case-control and cohort studies of the purported relationship between intrauterine devices (IUDs) and pelvic inflammatory disease (PID). STUDY SELECTION: Only studies of interval patients that included 50 or more women and 6 or more months of follow up that computed standard IUD event rates (rates of pregnancy and expulsion and removal for pain and bleeding) were selected for this study. All case-control and cohort studies identified were included except two case-control studies that included women with sterile chronic salpingitis. RESULTS: The 16 case-control and 2 cohort studies found or suggested that the Dalkon Shield increased the risk of PID. The 71 clinical trials of the Dalkon Shield show that when this device is inserted by an experienced clinician it is a safe and effective contraceptive method, comparable with other IUDs used at the time. There was no evidence of an increased risk of PID found in these clinical trials. CONCLUSIONS: This study offers convincing evidence that the indictment of the Dalkon Shield was a mistake. Additionally, this study shows that physician skill and experience is far more important to successful IUD insertion than previously recognized, a finding with considerable implications for IUD study designs and for marketing strategies.

Case-Control Studies