Patients' evaluation of outpatient medical care

150 patients attending an outpatient clinic at the University of Oklahoma Hospital over a 5-week period were asked whether the clinic care they were receiving was better than, as good as, or worse than the care they had received from local physicians. The patients were drawn from the general medicine, cardiology, and oncology-hematology units and tended to be elderly and chronically ill. Most of the patients viewed favorably the care they received in the medical outpatient clinics. 65% reported they had experienced pain or discomfort in the week prior to their visit, but there was no association between these factors and degree of satisfaction with clinic care. Patients averaged about 30 minutes with the physician, and 80% felt the doctor adequately explained their medical condition to them. Patients who rated the clinic care as being worse than the care of private practitioners felt that their condition was not adequately explained. When asked to define a "good doctor," patient responses were "interest in the patient," "skilled and thorough," and "explains things to you." Characteristics identified as being most important in a "good clinic" were; good doctors, well-trained staff, and information from doctors. Of all the factors examined, the one associated most directly with patient satisfaction was personal interest on the part of the physician in the patients.     

柳州市计生部门参与高危人群艾滋病综合干预效果分析

目的探讨计生部门参与高危人群艾滋病综合干预效果,探索该模式的有效性与可行性。方法选择100名计生干部进行培训,随机选择市区内35个社区内的吸毒人员及暗娼实施艾滋病防治综合干预,干预前进行基线调查,干预后做终期调查,对干预前后吸毒人员和暗娼的艾滋病相关知识知晓率、共用针具、安全套使用情况等进行比较分析。结果干预后吸毒人员及暗娼艾滋病相关的各个知识点知晓率明显高于干预前,差异有统计学意义(P<0.05);部分吸毒人员接受社区转介服务,共用针具情况明显改善,"最近1次注射吸毒是否与他人共用针具"由占总吸毒人员的62.9%降至30.7%,差异有统计学意义(P<0.01);暗娼使用安全套情况也明显改善,"从未使用"安全套的暗娼由干预前的26.8%降至干预后的4.5%,"最近1次性服务用安全套"由干预前的63.8%提高至干预后的97.2%,提高明显,差异有统计学意义(P<0.05)。结论计生部门参与艾滋病防治综合干预效果明显,是可行的,且可有效解决疾控中心人力物力不足所致的困难,是值得推广的干预模式。     

Development of a Health Management Support System for Patients with Diabetes Mellitus at Home

Recently, a patient with diabetes mellitus (DM) type 2 has been increasing in Japan. The patient should be managed not only by a specialist but also by himself focusing his attention on the improvement of his lifestyle at home. In the present study, we tried to develop a health management support system by which a diabetic patient in early stage can easily enter his daily life information, i.e. the biological information such as the data of blood sugar levels and blood pressure levels etc., the information of exercise and diet and send the information to the medical institution with a personal digital assistant (PDA). Afterwards, the patient can receive health instruction information by the physician in charge for self-care at his home with a PDA. The daily life information sent from the patient is stored in a server installed at the medical institution and analyzed. The physician can obtain the results of analysis by using a PC and send the instruction information necessary for patient management to the patient at home by using e-mail after diagnosing the patient’s condition by the system. To evaluate usability of the developed patient information input system with a PDA, an experiment was conducted by corporation of 20 volunteers who were possible self management and whose age’s range from 20s to 60s by questionnaire survey. As a result, almost examinees answered that lifestyle information could be easily entered by the sense like a mobile-phone and lots of positive opinions were obtained.     

Extracting medical information from narrative patient records: the case of medication-related information

Objective

While essential for patient care, information related to medication is often written as free text in clinical records and, therefore, difficult to use in computerized systems. This paper describes an approach to automatically extract medication information from clinical records, which was developed to participate in the i2b2 2009 challenge, as well as different strategies to improve the extraction.

Design

Our approach relies on a semantic lexicon and extraction rules as a two-phase strategy: first, drug names are recognized and, then, the context of these names is explored to extract drug-related information (mode, dosage, etc) according to rules capturing the document structure and the syntax of each kind of information. Different configurations are tested to improve this baseline system along several dimensions, particularly drug name recognition—this step being a determining factor to extract drug-related information. Changes were tested at the level of the lexicons and of the extraction rules.

Results

The initial system participating in i2b2 achieved good results (global F-measure of 77%). Further testing of different configurations substantially improved the system (global F-measure of 81%), performing well for all types of information (eg, 84% for drug names and 88% for modes), except for durations and reasons, which remain problematic.

Conclusion

This study demonstrates that a simple rule-based system can achieve good performance on the medication extraction task. We also showed that controlled modifications (lexicon filtering and rule refinement) were the improvements that best raised the performance.     

How and when to use the digitalis serum levels

The indications for measuring serum digoxin levels are suspicion of digitalis intoxication and the need to know the status of digitalization. Pitfalls of interpretation include time of serum sample relative to time of last digitalis dose, age of patient, atrial arrhythmia, electrolyte disturbances, disease state of the patient, recent radioisotopes "on board," abnormal absorption or metabolism, and laboratory error. The serum digoxin level is a useful clinical tool but only when employed with good judgment. Not every patient receiving digitalis requires the measurement of a blood level.     

Justified deception? The single blind placebo in drug research

"Run-in" and "washout" periods involving the withholding of medication are widely used in drug research trials in pursuit of both patient safety and scientific reliability. Such no-medication periods can be justified ethically provided that they are apparent to patients, who can thereby properly consent to undergoing them. Less widespread, but still common, is the practice of "single blinding" no-medication periods, concealing them from patients by means of placebo. Whilst all placebos involve a measure of concealment, their use is typically justified in drug research trials (i) by their preserving the uncertainty generated by the random allocation of different treatments within a drug trial; and (ii) by the researchers openly declaring both the randomisation process and the chances of receiving placebo. In the single blind placebo "run-in" or "washout", neither of these conditions is met. This paper considers three possible defences of the practice of using single blind placebo "run-ins" or "washouts" and finds them all to fail; the practice appears ethically unjustified.     

A neuroleptic malignantlike syndrome due to levodopa therapy withdrawal

Three cases of a syndrome resembling neuroleptic malignant syndrome are described in patients never exposed to neuroleptics. Each patient had a long history of Parkinson's disease treated with a carbidopa-levodopa combination. Two patients developed the syndrome when administration of the drug was discontinued temporarily. One developed the syndrome before the "drug holiday," and then died during the holiday because of this complication.     

Hemophilia and von Willebrand's disease: 2. Management. Association of Hemophilia Clinic Directors of Canada.

OBJECTIVE: To present current strategies for the treatment of hemophilia and von Willebrand's disease. OPTIONS: Prophylactic and corrective therapy with hemostatic and adjunctive agents: DDAVP (1-desamino-8-D-arginine vasopressin [desmopressin acetate]), recombinant coagulation products (human Factor VIII and human Factor VIIa) or virally inactivated plasma-derived products (high- or ultra-high-purity human Factor VIII or human Factor VIII concentrate containing von Willebrand factor activity, porcine Factor VIII, high-purity human Factor IX, human prothrombin-complex concentrate, human activated prothrombin-complex concentrate), adjunctive antifibrinolytic agents, topical thrombin and fibrin sealant. The induction of immune tolerance in patients in whom inhibitors develop should also be considered. OUTCOMES: Morbidity and quality of life associated with bleeding and treatment. EVIDENCE: Relevant clinical studies and reports published from 1974 to 1994 were examined. A search was conducted of our reprint files, MEDLINE, citations in the articles reviewed and references provided by colleagues. In the MEDLINE search the following terms were used singly or in combination: "hemophilia," "von Willebrand's disease," "Factor VIII," "Factor IX," "von Willebrand factor," "diagnosis," "management," "home care," "comprehensive care," "inhibitor," "AIDS," "hepatitis," "life expectancy," "complications," "practice guidelines," "consensus statement" and "controlled trial." The in-depth review included only articles written in English from North America and Europe that were relevant to human disease and pertinent to a predetermined outline. The availability of treatment products in Canada was also considered. VALUES: Minimizing morbidity and maximizing functional status and quality of life were given a high value. BENEFITS, HARMS AND COSTS: Proper prophylactic or early treatment with appropriate hemostatic agents minimizes morbidity and functional disability and improves quality of life. Economic gains are realized through the reduction of mortality and morbidity and their associated costs. The patient has a better opportunity to contribute to society through gainful employment and the fulfillment of social roles. Potential harms include HIV infection, hepatitis B, hepatitis C and the development of inhibitor antibodies to clotting-factor concentrates. The risk of viral transmission has been minimized through the development of procedures for the viral inactivation of plasma-derived clotting-factor concentrates and through the use of recombinant coagulation-factor concentrates and other non-plasma-derived hemostatic agents. RECOMMENDATIONS: DDAVP is the drug of choice for patients with mild hemophilia or type 1 or 2 (except 2B) von Willebrand's disease whose response to DDAVP in previous testing has been found to be adequate. Therapeutic blood components of choice include recombinant products and virally inactivated plasma-derived products. In Canada the recommended products are recombinant Factor VIII for hemophilia A, high-purity plasma-derived Factor IX for hemophilia B and plasma-derived Factor VIII concentrates containing adequate von Willebrand factor (e.g., Haemate P) for von Willebrand's disease. Dosages vary according to specific indications. Adjunctive antifibrinolytic agents, topical thrombin and fibrin sealant are useful for the treatment of oral or dental bleeds and localized bleeds in accessible sites. In patients with inhibitor antibodies, high-dose human or porcine Factor VIII is usually effective when the inhibitor titre is less than 5 Bethesda units/mL. In nonresponsive patients, or in those whose inhibitor titre is higher, "bypassing" agents (e.g., activated prothrombin-complex concentrate and recombinant Factor VIIa) are useful. Long-term management may include immune-tolerance induction.VALIDATION: These recommendations were reviewed and approved by the Association of Hemophilia Clinic Directors of Canada (AHCDC) and the Medical and Scientific Advisory Committee of the Canadian Hemophilia Society. No similar consensus statements or practice guidelines are available for comparison. SPONSORS: These recommendations were developed at the request of the Canadian Blood Agency, which funds the provision of all coagulation-factor concentrates for people with congenital bleeding disorders, and were developed and endorsed by the AHCDC and the Medical and Scientific Advisory Committee of the Canadian Hemophilia Society.     

General practice consultations: is there any point in being positive?

A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were randomly selected for one of four consultations: a consultation conducted in a "positive manner," with and without treatment, and a consultation conducted in a "non-positive manner," called a negative consultation, with and without treatment. Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups. Similarly, 64% of those receiving a positive consultation got better, compared with 39% of those who received a negative consultation (p = 0.001) and 53% of those treated got better compared with 50% of those not treated (p = 0.5).     

Mechanisms and management of stroke in the elderly.

OBJECTIVE: To highlight the mechanisms, common causes and management of stroke in the elderly. DATA SOURCES: MEDLINE was searched for articles published from 1967 to 1990. The following key words were used: "stroke," "cerebrovascular disease," "elderly," "aging," "hypertension," "drug interactions," "etiology," "evaluation," "management" and "recovery of function." Original articles with large series of patients were reviewed in detail. STUDY SELECTION: Of about 750 original articles reviewed 116 were finally selected for detailed analysis. Those that dealt with cause, pathophysiologic features and management of stroke with emphasis on the elderly were chosen. DATA SYNTHESIS: With increasing age the incidence of stroke increases, cardiovascular reserve decreases, catecholamine responsiveness diminishes and cardiac arrhythmias become more common. Blood pressure, especially systolic, rises, and the benefits of its treatment become both more difficult to assess and less certain. In the elderly population embolic stroke, particularly that due to nonvalvular atrial fibrillation, is seen with increasing frequency. Because of postural hypotension, cardiac arrhythmias and overmedication, watershed infarction occurs more frequently with increasing age. Amyloid angiopathy now represents the most common cause of spontaneous intracerebral hemorrhage. CONCLUSIONS: Because of the altered drug metabolism and pharmacodynamics in the elderly the therapeutic armamentarium is growing, and so are the risks of such treatments. Stroke in the elderly poses unique problems that deserve distinctive solutions. Further research is needed to study the effect of cerebral ischemia to understand better how the older brain handles the stress of the ischemic insult.     

Use of a viewdata system to collect data from a multicentre clinical trial in anaesthesia

The interactive electronic information storage and transmission system PRESTEL was assessed as a method of recording and collecting patient record forms from a multicentre trial in anaesthesia. PRESTEL terminals were provided in anaesthetic centres around Britain and all data handled by this public viewdata service, which connects users by telephone to a central computer. The trial was of a new analgesic supplement, alfentanil, and confirmed more rapid recovery of patients as compared with that after traditional anaesthesia with halothane. Advantages of the system were manifold and included reducing the need for the trial monitor to visit the trialist, an electronic "mailbox," confidentiality, and the ability immediately to identify violations of study protocol. No participant found the system too difficult to use, though the small keyboard was a source of complaint. Despite the initial cost of the system its utility vastly outweighs traditional methods of data collection.     

多层次模糊综合评价法在军队医院绩效评价中的应用

目的 用多层次模糊综合评价法科学合理地评价军队医院绩效.方法 对某军医大学附属医院2009-2011年度患者、财务、内部流程、学习成长4个维度的绩效进行评价,利用多层次模糊综合评价法得到各评价维度的模糊隶属度,并对评价结果进行对应分析.结果 目标医院2009-2011年度整体绩效综合评价等级隶属于“好”和“较好”的比例合计76.85％,根据最大隶属度原则,该医院整体绩效综合评价等级为“好”;对应分析结果显示财务维度“一般”,患者维度隶属于“差”或“较差”,内部流程维度隶属于“好”,学习成长维度隶属于“好”或“较好”.结论 多层次模糊综合评价方法较好地解决了系统多指标的综合问题,运用对应分析方法使评价结果更有合理性,更符合客观实际.     

Cardiomyopathy associated with the smoking of crystal methamphetamine

The smoking of crystal methamphetamine, or "ice," is a growing drug abuse problem in the United States. The toxic effects of methamphetamine smoking have not been well described. We describe two patients with cardiovascular toxic effects associated with the smoking of crystal methamphetamine. In our first patient, the use of smokeable methamphetamine was associated with the subsequent development of pulmonary edema and a dilated cardiomyopathy. In our second patient, the smoking of crystal methamphetamine likely produced diffuse vasospasm that resulted in acute myocardial infarction, cardiogenic shock, and death. The recognition of potentially lethal cardiac complications associated with the smoking of crystal methamphetamine is of extreme significance and should be emphasized to potential abusers of this drug.     

Aeromonas hydrophila sepsis in a patient undergoing hemodialysis therapy

Aeromonas hydrophila septicemia complicated by a generalized cutaneous vasculitis developed in a patient receiving home hemodialysis therapy. Because the Aeromonas organism is found in many natural water sources, the possibility that this patient's hemodialysis system became contaminated was explored. Although cultures from the patient's home environment showed no Aeromonas sp, the possibility still exists that the site of contamination was in the dialysis system.     

HARVEST,a longitudinal patient record summarizer

Objective To describe HARVEST, a novel point-of-care patient summarization and visualization tool, and to conduct a formative evaluation study to assess its effectiveness and gather feedback for iterative improvements.Materials and methods HARVEST is a problem-based, interactive, temporal visualization of longitudinal patient records. Using scalable, distributed natural language processing and problem salience computation, the system extracts content from the patient notes and aggregates and presents information from multiple care settings. Clinical usability was assessed with physician participants using a timed, task-based chart review and questionnaire, with performance differences recorded between conditions (standard data review system and HARVEST).Results HARVEST displays patient information longitudinally using a timeline, a problem cloud as extracted from notes, and focused access to clinical documentation. Despite lack of familiarity with HARVEST, when using a task-based evaluation, performance and time-to-task completion was maintained in patient review scenarios using HARVEST alone or the standard clinical information system at our institution. Subjects reported very high satisfaction with HARVEST and interest in using the system in their daily practice.Discussion HARVEST is available for wide deployment at our institution. Evaluation provided informative feedback and directions for future improvements.Conclusions HARVEST was designed to address the unmet need for clinicians at the point of care, facilitating review of essential patient information. The deployment of HARVEST in our institution allows us to study patient record summarization as an informatics intervention in a real-world setting. It also provides an opportunity to learn how clinicians use the summarizer, enabling informed interface and content iteration and optimization to improve patient care.     

Developing a Web 2.0 Diabetes Care Support System with Evaluation from Care Provider Perspectives

Diabetes is a life-long illness condition that many diabetic patients end up with related complications resulted largely from lacking of proper supports. The success of diabetes care relies mainly on patient’s daily self-care activities and care providers’ continuous support. However, the self-care activities are socially bounded with patient’s everyday schedules that can easily be forgotten or neglected and the care support from providers has yet been fully implemented. This study develops a Web 2.0 diabetes care support system for patients to integrate required self-care activities with different context in order to enhance patient’s care knowledge and behavior adherence. The system also supports care managers in a health service center to conduct patient management through collecting patient’s daily physiological information, sharing care information, and maintaining patient-provider relationships. After the development, we evaluate the acceptance of the system through a group of nursing staffs.     

Serum folate concentrations during pregnancy in women with epilepsy: relation to antiepileptic drug concentrations, number of seizures, and fetal outcome

Serum folate concentrations, blood counts, and antiepileptic drug concentrations were measured during 133 pregnancies of 125 women with epilepsy. There was an inverse correlation between serum folate concentrations and concentrations of phenytoin and phenobarbitone. The number of epileptic seizures during pregnancy showed no association with serum folate concentrations. No cases of maternal tissue folate deficiency or fetal damage attributable to low maternal serum folate were observed. Maternal serum folate concentrations for infants with structural birth defects, "fetal hydantoin syndrome," or perinatal death were similar to those for healthy babies. A low dose (100 to 1000 micrograms daily) of folate supplement appeared sufficient for pregnant women with epilepsy despite the antifolic action of antiepileptic medication. Monitoring folate concentrations in pregnant women with high serum concentrations of phenytoin or phenobarbitone is recommended.     

Low iron intakes among young women in Britain

A large survey by the Ministry of Agriculture, Fisheries and Food of people aged 15 to 25 showed that the women, and especially the participants "on a diet" or "watching their weight," generally had iron intakes well below the recommended daily allowance. Reduced iron intake appeared to result from diets of reduced iron concentration as well as from energy restriction. Further research is needed to establish whether this population is compromised or whether the current recommended daily allowances are unnecessarily high.     

BoB,a best-of-breed automated text de-identification system for VHA clinical documents

Objective

De-identification allows faster and more collaborative clinical research while protecting patient confidentiality. Clinical narrative de-identification is a tedious process that can be alleviated by automated natural language processing methods. The goal of this research is the development of an automated text de-identification system for Veterans Health Administration (VHA) clinical documents.

Materials and methods

We devised a novel stepwise hybrid approach designed to improve the current strategies used for text de-identification. The proposed system is based on a previous study on the best de-identification methods for VHA documents. This best-of-breed automated clinical text de-identification system (aka BoB) tackles the problem as two separate tasks: (1) maximize patient confidentiality by redacting as much protected health information (PHI) as possible; and (2) leave de-identified documents in a usable state preserving as much clinical information as possible.

Results

We evaluated BoB with a manually annotated corpus of a variety of VHA clinical notes, as well as with the 2006 i2b2 de-identification challenge corpus. We present evaluations at the instance- and token-level, with detailed results for BoB''s main components. Moreover, an existing text de-identification system was also included in our evaluation.

Discussion

BoB''s design efficiently takes advantage of the methods implemented in its pipeline, resulting in high sensitivity values (especially for sensitive PHI categories) and a limited number of false positives.

Conclusions

Our system successfully addressed VHA clinical document de-identification, and its hybrid stepwise design demonstrates robustness and efficiency, prioritizing patient confidentiality while leaving most clinical information intact.