Parotitis associated with Crimean Congo hemorrhagic fever virus

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal tick-borne viral disease, the course of which may accompanied by various clinical findings.

Objectives

We describe a picture of non-suppurative parotitis developing in association with CCHF virus.

Study design

A 48-year-old patient presenting to our hospital with lethargy, hemorrhage and pain and swelling below the left ear was diagnosed with CCHF through IgM antibody and polymerase chain reaction positivity in serum investigated for CCHF virus. A picture of non-suppurative parotitis developed on the 3rd day of admission.

Results

Other causes of parotitis were excluded with the help of serological tests, and the case was regarded as one of CCHF-associated parotitis. The patient was put on adjuvant therapy, an improvement in clinical findings was observed and he was discharged in a healthy condition on the 8th day.

Conclusions

Ours is the first case in the literature of parotitis seen during CCHF. CCHF should be considered in differential diagnosis in addition to other frequently encountered viral agents in patients from endemic regions presenting with a picture of non-suppurative parotitis.     

Glucocorticoids do not reduce subjective fear in healthy subjects exposed to social stress

Background

Previous experiments in patients with phobia have shown that the administration of glucocorticoids reduces fear in phobic situations. Extensive evidence indicates that elevated glucocorticoid levels inhibit memory retrieval processes. In patients with phobia, exposure to a phobic stimulus (socio-evaluative stress test) provokes retrieval of stimulus-associated fear memory that leads to a fear response. It is therefore possible that glucocorticoids reduce phobic fear by inhibiting retrieval of the previously acquired fear memory. Whether glucocorticoids reduce subjective fear also in healthy subjects exposed to a socially fearful situation is not known.

Method

In a double-blind, placebo-controlled study, 50 healthy subjects underwent the same socio-evaluative stress test as used in a previous study in patients with social phobia. One hour before the stress test, subjects received 25 mg cortisone or placebo orally. Psychological anxiety measures were repeatedly assessed.

Results

Although the stress situation robustly increased fear in this population of healthy subjects, cortisone treatment did not reduce subjective fear, physical discomfort or avoidance behavior when compared to placebo-treated subjects.

Conclusion

The present study did not find evidence indicating that glucocorticoids reduce subjective fear in healthy subjects exposed to a socially fearful situation.     

A multi-module case-based biofeedback system for stress treatment

Objective

Biofeedback is today a recognized treatment method for a number of physical and psychological problems. Experienced clinicians often achieve good results in these areas and their success largely builds on many years of experience and often thousands of treated patients. Unfortunately many of the areas where biofeedback is used are very complex, e.g. diagnosis and treatment of stress. Less experienced clinicians may even have difficulties to initially classify the patient correctly. Often there are only a few experts available to assist less experienced clinicians. To reduce this problem we propose a computer-assisted biofeedback system helping in classification, parameter setting and biofeedback training.

Methods

The decision support system (DSS) analysis finger temperature in time series signal where the derivative of temperature in time is calculated to extract the features. The case-based reasoning (CBR) is used in three modules to classify a patient, estimate parameters and biofeedback. In each and every module the CBR approach retrieves most similar cases by comparing a new finger temperature measurement with previously solved measurements. Three different methods are used to calculate similarity between features, they are: modified distance function, similarity matrix and fuzzy similarity.

Results and conclusion

We explore how such a DSS can be designed and validated the approach in the area of stress where the system assists in the classification, parameter setting and finally in the training. In this case study we show that the case based biofeedback system outperforms trainee clinicians based on a case library of cases authorized by an expert.     

Psychological factors associated with the incidence and persistence of suicidal ideation

Background

Suicidal ideation has been identified as both a common antecedent and a significant risk factor for suicide attempt and completed suicide. However, little is known about the incidence and persistence of suicidal ideation in the general population and the associated risk factors.

Methods

A 12-month follow-up survey investigated 997 of the respondents who participated in the baseline territory-wide survey of adult population in Hong Kong. A set of baseline psychological factors was considered as predictors of first onset and persistence of suicidal ideation.

Results

Twelve-month incidence (1.9%) and persistence (6.2%) rates were estimated. Respondents with anxiety and lack of reasons for living were more likely to report a development of suicidal thoughts in the follow-up assessment, while respondents with higher level of average life distress and lower level of hope were at increased risk of continuing to have suicidal thoughts. Depression was found to partially mediate the effect of average life distress on persistent suicidality.

Limitations

Retention rate of the follow-up sample was about 50% only. Assessments of suicidal ideation were based on retrospective reports.

Conclusions

Psychological factors differentially predict first onset and persistence of suicidal ideation. It is of clinical value that depression partially mediated the effect of life distress on persistence of suicidality.     

Modeling surgical processes: a four-level translational approach

Motivation

The precise and formal specification of surgical interventions is a necessary requirement for many applications in surgery, including teaching and learning, quality assessment and evaluation, and computer-assisted surgery. Currently, surgical processes are modeled by following various approaches. This diversity lacks a commonly agreed-upon conceptual foundation and thus impedes the comparability, the interoperability, and the uniform interpretation of process data.

Objective

However, it would be beneficial if scientific models, in the same context, shared a coherent conceptual and formal mathematical basis. Such a uniform foundation would simplify the acquisition and exchange of data, the transition and interpretation of study results, and the transfer and adaptation of methods and tools. Therefore, we propose a generic, formal framework for specifying surgical processes, which is presented together with its design methodology.

Methods

The methodology follows a four-level translational approach and comprises an ontological foundation for the formal level that orients itself by linguistic theories.

Results

A unifying framework for modeling surgical processes that is ontologically founded and formally and mathematically precise was developed. The expressive power and the unifying capacity of the presented framework are demonstrated by applying it to four contemporary approaches for surgical process modeling by using the common underlying formalization.

Conclusions

The presented four-level approach allows for capturing the knowledge of the surgical intervention formally. Natural language terms are consistently translated to an implementation level to support research fields where users express their expert knowledge about processes in natural language, but, in contrast to this, statistical analysis or data mining need to be performed based on mathematically formalized data sets. The availability of such a translational approach is a valuable extension for research regarding the operating room of the future.     

How to use contextual knowledge in medical case-based reasoning systems: a survey on very recent trends

Objectives

This paper aims at systematizing the ways in which the contextual knowledge embedded in the case library can support decision making, within case-based reasoning (CBR) systems. In particular, CBR applications to the medical domain are considered.

Methods and material

After a quick survey on the definition and on the role of context in artificial intelligence research, we have focused on CBR, with a particular emphasis on medical applications. In this field, we have identified a number of very recent contributions, which strongly recognize context per se as a major knowledge source. These contributions propose to maintain and to rely on contextual information, in order to support human reasoning in different fashions.

Results

We have distinguished three main directions in which contextual knowledge can be resorted to, in order to optimize physicians’ decision making. Such directions can be summarized as follows: (1) to reduce the search space in the case retrieval step; (2) to maintain the overall knowledge content always valid and up to date, and (3) to adapt knowledge application and reasoning to local/personal constraints. We have also properly categorized the surveyed works within these three clusters, and identified the most significant ones, able to exploit contextual knowledge along more than one direction.

Conclusions

Innovative applications of the contextual knowledge recorded in the case library, described and systematized in this paper, can trace promising research directions for the future.     

Determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications: a theoretical approach

Objective

To quantify and compare the determinants of different types of medication non-adherence in cholesterol lowering and asthma maintenance medications using a theoretical approach.

Methods

Study design was online cross sectional survey. A conceptual framework was developed using Andersen's Behavioral Model and Leventhal's Common Sense Model to understand the determinants of medication non-adherence. Regression analyses were used to test the models for predicting non-adherence.

Results

The models based on Andersen's Behavioral Model and Leventhal's Common Sense Model were significant. While predisposing factors such as treatment convenience and beliefs in medications were significant in cholesterol lowering medications, need factors such as illness perceptions and disease severity were significant in asthma maintenance medications. Among the enabling factors, self efficacy was a significant predictor in both cholesterol lowering and asthma maintenance medications.

Conclusion

Different determinants explained different types of non-adherence and suggest the need to consider different types of non-adherence for different medications as well as different determinants for each type of non-adherence.

Practice implications

Identifying determinants of different types of non-adherence can help health care professionals develop targeted interventions which can be more successful than the current model of single and generalized interventions to reduce non-adherence.     

Attitudes of physical therapy students toward patient-centered care, before and after a course in psychosocial aspects of care

Objective

Patient-centered care is vital in developing the therapeutic relationship. Attitude may be an important measure of student potential for giving patient-centered care. The purpose of this study was to assess attitudes toward patient-centered care in doctor of physical therapy students before and after completion of a course that addresses communication skills and psychosocial aspects of care.

Methods

In 2009, forty-nine students in the Doctor of Physical Therapy educational program at Duke University took a required course which included recommended elements for teaching patient-centered care. Students completed the Patient-Practitioner Orientation Scale (PPOS) and the Tasks of Medicine Scale (TOMS) twice prior to the course and once at course completion. Demographic data were gathered and students responded to open-ended questions at final survey administration.

Results

There were statistically significant differences in student attitudes toward patient-centered care after the educational experience on the PPOS and the TOMS, which were supported by students’ written responses.

Conclusion

Changes in attitudes toward patient-centered care are possible with educational intervention.

Practice implications

The results of this study may help to inform educators of medical professionals about the education of practitioners to develop patient-centered attitudes.     

Does the effect go up in smoke? A randomized controlled trial of pictorial warnings on cigarette packaging

Objective

Placing a combination of a written warning and a graphic image on cigarette packaging (so called “pictorial warnings”) is one of the WHO Framework Convention on Tobacco Control's most controversial recommendations. Our randomized controlled trial investigated if pictorial warnings lead to significantly higher motivation to quit, as compared to written warnings alone.

Methods

Four pictorial warnings were selected from the EU Commission's official image catalogue. Study arm 1 (44 adult smokers) viewed only the written warnings while study arm 2 (44 adult smokers) viewed the corresponding pictorial warnings. Self-affirmation was a second randomly manipulated factor, and nicotine dependence a quasi-experimental third factor. The main outcome measured was the motivation to quit, with fear intensity as one of the secondary outcomes.

Results

Pictorial warnings were associated with a significantly higher motivation to quit. A pictorial warning was also associated with higher fear intensity. The effect of warnings appears to be independent of nicotine dependence and self-affirmation.

Conclusions

Nationwide implementation of pictorial warnings may be effective in increasing heavy smokers’ motivation to quit.

Practice implication

Due to the fact that perceived vulnerability, response and self-efficacy are not more strongly affected by pictorial warnings this effect may turn out to be short-term.     

A biomedical sensor system for real-time monitoring of astronauts’ physiological parameters during extra-vehicular activities

Objective

To design and test an embedded biomedical sensor system that can monitor astronauts’ comprehensive physiological parameters, and provide real-time data display during extra-vehicle activities (EVA) in the space exploration.

Methods

An embedded system was developed with an array of biomedical sensors that can be integrated into the spacesuit. Wired communications were tested for physiological data acquisition and data transmission to a computer mounted on the spacesuit during task performances simulating EVA sessions.

Results

The sensor integration, data collection and communication, and the real-time data monitoring were successfully validated in the NASA field tests.

Conclusions

The developed system may work as an embedded system for monitoring health status during long-term space mission.     

Use of real-time polymerase chain reaction (rtPCR) as a diagnostic tool for influenza infection in a vaccine efficacy trial

Background

Conventional techniques for diagnosing influenza based on viral cell culture or disease serology have limitations, and molecular assays, such as real-time polymerase chain reaction (rtPCR) are increasingly used.

Objectives

To evaluate the use of rtPCR as a diagnostic tool for the determination of influenza virus infection.

Study design

This prospective, double-blind, placebo-controlled, randomised efficacy study was conducted in persons aged 18-64 years. Cases of influenza-like-illness (ILI), defined as at least one systemic symptom [fever ≥37.8 °C and/or myalgia] and at least one respiratory symptom [cough and/or sore throat] were identified by active and passive surveillance. For each case of suspected ILI, nasal and throat swabs were collected and analysed by viral culture and rtPCR.

Results

227 ILI cases were positive by rtPCR while 64% (145/227) were positive by both rtPCR and culture. For both assays, the maximum percentage of swabs that tested positive was on Day 0, thereafter positive samples by rtPCR remained constant until Day 5 but decreased progressively by culture. All rtPCR positive cases with a viral load of below 4.5 log₁₀ copies/sample were negative by culture. There were however culture negative cases with high viral loads. Vaccine efficacy for influenza was estimated as 54.7% by rtPCR (culture positive or negative) and 61.6% by culture irrespective of match to vaccine strain. Clinical severity was not significantly different between culture positive cases and culture negative but rtPCR positive cases.

Conclusions

rtPCR is a sensitive and specific diagnostic tool for influenza vaccine efficacy studies.     

eXiT*CBR: A framework for case-based medical diagnosis development and experimentation

Objective

Medical applications have special features (interpretation of results in medical metrics, experiment reproducibility and dealing with complex data) that require the development of particular tools. The eXiT*CBR framework is proposed to support the development of and experimentation with new case-based reasoning (CBR) systems for medical diagnosis.

Method

Our framework offers a modular, heterogeneous environment that combines different CBR techniques for different application requirements. The graphical user interface allows easy navigation through a set of experiments that are pre-visualized as plots (receiver operator characteristics (ROC) and accuracy curves). This user-friendly navigation allows easy analysis and replication of experiments. Used as a plug-in on the same interface, eXiT*CBR can work with any data mining technique such as determining feature relevance.

Results

The results show that eXiT*CBR is a user-friendly tool that facilitates medical users to utilize CBR methods to determine diagnoses in the field of breast cancer, dealing with different patterns implicit in the data.

Conclusions

Although several tools have been developed to facilitate the rapid construction of prototypes, none of them has taken into account the particularities of medical applications as an appropriate interface to medical users. eXiT*CBR aims to fill this gap. It uses CBR methods and common medical visualization tools, such as ROC plots, that facilitate the interpretation of the results. The navigation capabilities of this tool allow the tuning of different CBR parameters using experimental results. In addition, the tool allows experiment reproducibility.     

Development and psychometric properties of a self report measure to assess clinicians' practices in self management support for patients with long term conditions

Objective

This paper presents a process of developing practices in self management support (PSMS) - a measure assessing clinicians’ self reported use of self management support practices in clinical consultations for patients with long term conditions (LTCs).

Methods

The development process comprised the following steps: literature review to define what skills clinicians need to effectively support patients to self manage, review of existing measures of SMS practices, construction of an initial pool of items, E Delphi study pilot survey to select items for final measure, data collection to confirm the factor structure and internal consistency of the final measure.

Results

The PSMS comprises three subscales: Clinical SMS (14 items), Patient Centeredness (4 items) and Organizational SMS (7 items). All subscales have very good internal reliability (Cronbach α: 0.94, 0.78 and 0.85; all item-total correlations above 0.50).

Conclusions and practice implications

We believe PSMS measure is suitable for both research and programme evaluation in UK clinical settings. To complete the process of measure development we are now planning to conduct further analyses to establish the validity of PSMS measure in UK and non UK healthcare settings and test the validity of PSMS measure on a wider range of other LTC groups.     

Évaluation du kit Fluo-RAL (RAL) pour la recherche de mycobactéries en microscopie à fluorescence

Aim of the study

This study has examined the sensitivity of a commercially available fluorochrome stain, the Fluo-RAL kit (RAL), in comparison to the Degommier's stain as gold standard.

Materials and methods

Hundred and thirty-three twin smears, made directly from samples or after their decontamination with N-acetyl-L-cysteine NaOH, were stained, the first slide with the Degommier's method and the second with the Fluo-RAL kit. The samples were 58 sputums, 31 broncho-aspirations, nine gastric lavages, 11 bronchoalveolar lavages, six pleural fluids, two cerebro-spinal fluids, 11 biopsies, two blood cultures and two deep pus. They were examined with 400 × objective under standard fluorescence UV filter by two laboratory technicians independently. The results were expressed with semi-quantitative mean from 0 to 4+.

Results

Hundred and thirty-two results were agreed in grading between the two methods: 73 negative smears, nine quantified as rare (1+), 11 as few (2+), 32 as moderate (3+) and seven as numerous (4+). The only discrepant result had concerned a positive smear quantified as 1+ with the Degommier's stain and as 2+ with the Fluo-RAL kit. This discrepancy was confirmed after a second examination.

Conclusion

After this study, the Fluo-RAL kit was considered as agreed for its daily use in our laboratory. It improves the standardisation of fluorescence microscopy without additional cost or waste of time and reduces the chemical risk in the laboratory. This test, associated with reading using light-emitting diodes, could allow the development of fluorescence microscopy, the higher sensitive method for direct diagnosis of tuberculosis, in poor-resource countries where tuberculosis is a public health problem.     

A Multiple Indicators Multiple Causes (MIMIC) model of Behavioural and Psychological Symptoms in Dementia (BPSD)

Introduction

Although there is evidence for distinct behavioural sub-phenotypes in Alzheimer's disease (AD), their inter-relationships and the effect of clinical variables on their expression have been little investigated.

Methods

We have analysed a sample of 1850 probable AD patients from the UK and Greece with 10 item Neuropsychiatric Inventory (NPI) data. We applied a Multiple Indicators Multiple Causes (MIMIC) approach to investigate the effect of MMSE, disease duration, gender, age and age of onset on the structure of a four-factor model consisting of “psychosis”, “moods”, “agitation” and “behavioural dyscontrol”.

Results

Specific clinical variables predicted the expression of individual factors. When the inter-relationship of factors is modelled, some previously significant associations are lost. For example, lower MMSE scores predict psychosis, agitation and behavioural dyscontrol factors, but psychosis and mood predict the agitation factor. Taking these associations into account MMSE scores did not predict agitation.

Conclusions

The complexity of the inter-relations between symptoms, factors and clinical variables is efficiently captured by this MIMIC model.     

Bulimia nervosa and evidence for striatal dopamine dysregulation: a conceptual review

Objective

This article reviews concepts and evidence, based in particular on the work of Bartley G. Hoebel and colleagues, which suggest that a better understanding of the role of striatal dopamine (DA) in the initiation and/or maintenance of bulimia nervosa (BN) may result in a clearer characterization of mechanisms underlying BN.

Methods

Literature review, using PubMed search.

Results

Several lines of evidence, including the work of Bartley G. Hoebel, implicate the importance of striatal DA in feeding behavior, as well as in the disordered eating behaviors relevant to BN. Preclinical models of ‘BN-like’ eating behaviors have been associated with changes in striatal DA and DA receptor measures. Emerging clinical research also suggests that striatal DA abnormalities exist in individuals with BN.

Conclusion

Alterations in striatal DA may exist in patients with BN. While the precise relationship between these findings and the etiology and maintenance of bulimic symptomatology remains unclear, further investigation of brain DA systems is a fruitful avenue of future research in BN.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.