Digital documentation of the physical examination: moving the clinical breast exam to the electronic medical record

BACKGROUND: Documentation of the clinical breast examination (CBE) has consisted of simple hand-drawings and stick figures without a common lexicon. There is a need for a device that can accurately depict the CBE in digital format while being objective, reproducible over time, and useable in the electronic medical record. This new device is called palpation imaging (PI). METHODS: We examined 110 patients with a complaint of a breast mass using PI. This laptop-sized device creates a real-time digital display of the palpable area in both video and still formats. The size, hardness, shape, homogeneity, and mass location may be extracted from the image. RESULTS: Of those with a true mass, PI identified the mass in 94% while physical examination identified 86%. The positive predictive value (PPV) for breast cancer using PI was 94% and 78% for physical examination. A survey of primary care physicians revealed the inclusion of the PI record in a consultation note implied competence, experience, and skill by the surgeon. CONCLUSIONS: PI documented the CBE in a timely, efficient, and accurate manner. A reproducible record allows objective review by multiple examiners at varied times. Continued work will optimize examination methods.     

Explaining recent increases in students' marijuana use: impacts of perceived risks and disapproval, 1976 through 1996.

OBJECTIVES: Marijuana use among high school seniors increased during most of the 1970s, decreased throughout the 1980s, and has been increasing again during the 1990s. Earlier analyses of the classes of 1976 through 1986 attributed the historic trends during that period to specific changes in views about marijuana. This study examined whether recent increases in marijuana use among seniors and among students in earlier grades reflect similar processes. METHODS: Multivariate regression analyses were conducted on data from large annual nationwide surveys of high school seniors from 1976 through 1996 (approximate n = 61,000) and 8th and 10th graders from 1991 through 1996 (n''s = 87,911 and 82,475, respectively). RESULTS: Individual lifestyle factors (grades, truancy, religious commitment, evenings out for recreation) correlated substantially with marijuana use but did not explain the historic changes in marijuana use. Rather, decreases in perceived risk of harmfulness and in disapproval can account for the recent increases in all 3 grades and for earlier decreases among seniors. CONCLUSIONS: These findings indicate that perceived risks and disapproval are important determinants of marijuana use. Accordingly, prevention efforts should include realistic information about risks and consequences of marijuana use.     

Microelectrode arrays fabricated using a novel hybrid microfabrication method

We present novel hybrid microfabrication methods for microelectrode arrays that combine microwire assembly, microelectromechanical systems (MEMS) manufacturing techniques and precision tool-based micromachining. This combination enables hybrid microfabrication to produce complex geometries and structures, increase material selection, and improve integration. A 32-channel shank microelectrode array was fabricated to highlight the hybrid microfabrication techniques. The electrode shank was 130 μm at its narrowest, had a 127 μm thickness and had iridium oxide electrode sites that were 25 μm in diameter with 150 μm spacing. Techniques used to fabricate this electrode include microassembly of insulated gold wires into a micromold, micromolding the microelectrode shank, post molding machining, sacrificial release of the microelectrode and electrodeposition of iridium oxide onto the microelectrode sites. Electrode site position accuracy was shown to have a standard deviation of less than 4 μm. Acute in vivo recordings with the 32-channel shank microelectrode array demonstrated comparable performance to that obtained with commercial microelectrode arrays. This new approach to microelectrode array fabrication will enable new microelectrodes, such as multi-sided arrays, drug eluding electrodes and biodegradable shanks.     

Funding mechanisms for depression care management: opportunities and challenges

OBJECTIVE: Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. METHOD: We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." RESULTS: Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. CONCLUSIONS: While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices.