Intelligent dialogue based on statistical models of clinical decision-making

The independence Bayesian model has been used widely in computer programs designed to support clinical decision-making. A reasoning strategy has been developed to enable these programs to conduct clinically pertinent dialogue and explain their reasoning. It has been implemented in a program for the diagnosis of acute abdominal pain based on the Bayesian model of de Dombal et al. Several features of the dialogue design have been adopted from artificial intelligence research, including shared initiative and critiquing. The program adopts a flexible goal-driven strategy, attempting to confirm the clinician's diagnosis or rule out the likeliest alternative. Symptoms and signs are selected in order of their expected weights of evidence in favour of the hypothesized disease.     

Comparison of the APACHE III, APACHE II and Glasgow Coma Scale in acute head injury for prediction of mortality and functional outcome

Objectives: This study examines the efficacy of the predicting power for hospital mortality and functional outcome of three different scoring systems for head injury in a neurosurgical intensive care unit (NICU). Design: On the day of admission, data were collected from each patient to compute the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II and III, and Glasgow Coma Scale (GCS) scores. Hospital mortality was defined as the deaths of patients before discharge from hospital. Early mortality was defined as death before the 14th day after admission. Late mortality was defined as death after the 15th day from admission. Functional outcome was evaluated by Index of Independence in Activities of Daily Living (Index of ADL). Setting: An 8-bed NICU in a 1270-bed medical center in Taichung Veterans General Hospital. Patients and participants: Two hundred non-selected patients with acute head injury were included in our study in a consecutive period of 2 years. Patients less than 14 years old were not included. Interventions: None. Measurements and results: Sensitivity, specificity and correct prediction outcome were measured by the chi-square method in three scoring systems. The Youden index was also obtained. The best cut-off point in each scoring system was determined by the Youden index. The difference in Youden index was calculated by Z score. A difference was also considered if the probability value was less than 0.05. The area under Receiver Operating Characteristic (ROC) curve was computed. Then the area under ROC of each scoring system was compared by Z score. There was statistical significance if p was less than 0.05. For prediction of hospital mortality, the best cut-off points are 55 for APACHE III, 17 for APACHE II and 5 for GCS. The correct prediction outcome is 82.4% in APACHE III, 78.4% in APACHE II and 81.9% in the GCS. The Youden index has best cut-off points at 0.68 for APACHE III, 0.59 for APACHE II, and 0.56 for GCS. The area under Receiver Operating Characteristic (ROC) curve is 0.90 in the APACHE III, 0.84 in the APACHE II and 0.86 in the GCS. There are no statistical differences among APACHE III and II, and GCS in terms of correct prediction outcome, Youden Index and the area under the ROC curve. Other physiological variables excluding GCS in APACHE III and II (AP III-GCS, AP II-GCS) have less statistical value in the determination of mortality for acute head injury. For the prediction of late mortality, APACHE III and II yield significantly better results in the area under the ROC curve, correct prediction and Youden index than those of GCS. Other physiological variables (AP III-GCS and AP II-GCS) play an important role in the prediction of late mortality in APACHE scores. For prediction of the functional outcome of surviving patients with acute head injury, the APACHE III yields the best results of correct prediction outcome, Youden index and the area under the ROC curve. Conclusion: The APACHE III and II may not replace the role of GCS in cases of acute head injury for hospital or early mortality assessment. But for prediction of the late mortality, the APACHE III and II have better accuracy than GCS. Other physiological variables excluding GCS in the APACHE system play a crucial contribution for late mortality. GCS is simple, less time-consuming and economical for patients with acute head injury for the prediction of hospital and early mortality. The APACHE III provides better prediction for severe morbidity than GCS and APACHE II. Therefore, the APACHE III provides a good assessment not only for hospital and late mortality, but also for functional outcome. Received: 22 May 1995 Accepted: 2 September 1996     

Inter-rater reliability of the original and modified Barthel Index,and a comparison with the Functional Independence Measure

The Barthel Index (BI), the Modified Barthel Index (MBI) and the Functional Independence Measure (FIM) are all widely used by occupational therapists as assessment tools for clinical decision-making and outcome measurement. All of these tools have demonstrated validity and the BI and the FIM have demonstrated inter-rater reliability. The MBI has been modified to increase sensitivity; however, there have been no publications on the inter-rater reliability of this tool following the changes. The purpose of this research was to examine the inter-rater reliability of two versions of the Barthel Index, and draw some comparisons between this assessment tool and the FIM. Twenty-five patients with neurological and orthopaedic conditions were assessed by three occupational therapists using the three tools. The method of analysis selected was percentage agreement and intraclass correlation coefficient. The results indicated that both the original and modified versions of the Barthel Index possess good inter-rater reliability. As all three tools have demonstrated adequate reliability and validity, it is suggested that clinicians select the most sensitive tool that best meets their clinical needs, and use this assessment tool in its standardized format.     

The rheumatic patient''s early needs and expectations

During the last few years, studies have revealed that the need for psychosocial support and concrete social services are great in the early stages of the treatment of rheumatic diseases. The ability to keep a job, to do household chores, to participate in leisure activities and to maintain social relations is clearly impaired. Anxiety and depression are not unusual and often associated with weak support from relatives, loneliness and disturbed family relations. Nevertheless, the patients report resilience and determination to cope with the impacts of illness. Crisis intervention, vocational guidance and counselling about problems concerning the disease should be available and offered to the patients. As the patients seem to be unaccustomed to talking about their psychosocial problems, an empathetic and information-seeking attitude on the part of the health care staff is essential.     

Differences in the abilities of individual fingers during the performance of fast,repetitive tapping movements

Using 12 healthy male subjects, the dynamic motor ability of individual fingers was investigated under four different finger tapping conditions. These were: maximum speed tapping with one finger (single-finger tapping), alternate movement of two fingers (double-finger tapping), double-finger tapping in an unsupported condition, and submaximum constant speed tapping with one finger in a passive manner. Key-contact forces for all fingers and the movement velocity of the tapping finger were monitored. With the exception of the unsupported condition, non-tapping fingers were maintained in contact with designated keys during the tapping tasks. It was found that the index finger attained the fastest cadence and greatest movement velocity, followed by the middle, little and ring fingers, respectively. Subjective assessment of rank order of "difficulty" of tapping by the subjects was highly correlated with tapping cadence. Thus dynamic motor function, as indicated by rapid, repetitive movement, differs among the individual fingers. Parallel changes were observed in the key-contact force of the neighboring non-tapping fingers during tapping. The range of the non-tapping finger forces was largest during tapping by the ring finger. A similar trend was found for passive tapping, during which the magnitude of key-contact force was less than one-third of that observed during active tapping. The lower cadence achieved by the ring finger may be attributed more to a lack of independence at the level of voluntary neuromuscular control, than to innate mechanical interaction with the other fingers. Tapping cadence of each finger was lower for the double-finger mode than for the single-finger mode. The magnitude of the observed decrease in cadence during double-finger tapping was, on the other hand, strongly dependent on finger-combination. The decrease was smallest for the index-middle finger-combination, and greatest for the ring-little finger-combination. Compatibilities with other fingers can play an essential role in the dynamic motor function of individual fingers. During the unsupported task, in which interactions were diminished by allowing all fingers to move freely, tapping cadence increased markedly. Therefore, the lower cadences observed in specific finger-combinations may be partly attributed to anatomical and neural interdigit interactions.     

Self-management and spina bifida: A systematic review of the literature

BackgroundSelf-management is critical to optimizing the health of individuals with a chronic condition or disability and is, therefore, a central concept in individual and family-centered healthcare delivery. The purpose of this review is to report the state of the science of self-management for individuals with spina bifida (SB) from a lifespan perspective.ObjectiveThis review will summarize the (a) development and use of self-management skills and behaviors across the life span, (b) factors related to self-management behaviors, (c) development of generic or condition-specific measures of self-management used with a spina bifida population, and (d) development and/or outcomes of interventions to improve self-management in SB.MethodsThe search strategy was limited to primary research articles published between 2003 and 2019 and followed PRISMA guidelines. The databases searched included: PubMed, CINAHL, PsycINFO, Web of Science, Cochrane, and Google Scholar. Studies that addressed self-management concepts in individuals throughout the life span and published in English were included.ResultsThe search yielded 108 citations and 56 articles met inclusion/exclusion criteria. A systematic narrative synthesis was reported. The level of evidence identified was primarily Level III articles of good quality. Multiple demographic, environmental, condition and process factors were related to self-management behaviors. SB self-management instruments and intervention development and testing studies were identified.ConclusionsThis review provides a synthesis of the state of the science of self-management including factors related to self-management behaviors, preliminary evidence of instruments for use in SB, factors important to consider in the development and testing of future interventions, and gaps in the literature.     

A 10-year follow up of a paging service for people with memory and planning problems within a healthcare system: How do recent users differ from the original users?

In 2003 Wilson, Scott, Evans, and Emslie published a report of a new healthcare resource; a paging system designed to reduce the everyday problems of people with neurological deficits who experience memory and/or planning problems. The system was established following several research studies carried out to evaluate its effectiveness. Information was collected on the first 40 clients recruited to the service. The purpose of the present study is to determine how the service might have changed over a 10-year period. The most recent users of the service (N?=?40) have been compared with the original cohort of 40 clients. In addition, in 2007 clients were given the opportunity to use their mobile telephones to receive messages; 17 chose to do so. There was no difference in age between the telephone users compared to the pager users, but those using a pager were less likely to have sustained a traumatic brain injury (TBI) and were more likely to be longer post-insult. There were no significant differences in the gender or ages of the people using the pager compared with those using the telephone service. However, the mean overall time since injury for the last 40 referrals was 9.48 years compared to 4.56 years for the original cohort. Both cohorts comprised several diagnostic groups; clients with TBI formed the largest subgroup, followed by those with stroke. This is typical of patients seen for rehabilitation, with other diagnostic groups forming a smaller percentage. We wanted to determine whether the range of diagnoses was similar over the 10-year period. Despite slight differences, we found a similar range of patients referred. In both cohorts the most frequent messages sent each week related to medication (27.9% in the first compared to 28.6% in the second). More messages were sent regarding mood management in the second cohort. No such messages were sent to the first 40 clients, whereas over 27 per week were sent to the last 40. Fewer health authorities (N?=?21) were referring after 10 years in comparison with 26 referrers for the first cohort.     

Essentially Winnicott: Creating Psychic Health

The authors of this paper recognize the paradox of identifying with the body of work of D. W. Winnicott as it was essential to his view that each analyst has to become the analyst s/he is or can be. This is to avoid the dead hand of conformity and falsity. Nevertheless his work continues to inspire creative use with its concern with health and those conditions for its development. Both authors find themselves committed to history taking, to needing and taking time, to a willingness to wait before interpreting, to a recognition that the self derives originally from a bodily state of unintegration, that the body remains significant for the expression of self‐states, to an understanding of aggression as not primarily associated with destructiveness, to attending to the state of mind in the analyst that encourages the establishment and maintenance of the analytic setting. Clinically their intention is to maintain a continuity within which psychic change can be facilitated, through an attention to the ongoing exchanges between both parties of the analytic relation. Several clinical examples are given from different settings to illustrate the presence of these tenets in their work.