Patients Are Knowledge Workers in the Clinical Information Space

Background  Limited research exists on patient knowledge/cognition or “getting inside patients'' heads.” Because patients possess unique and privileged knowledge, clinicians need this information to make patient-centered and coordinated treatment planning decisions. To achieve patient-centered care, we characterize patient knowledge and contributions to the clinical information space. Methods and Objectives  In a theoretical overview, we explore the relevance of patient knowledge to care provision, apply historical perspectives of knowledge acquisition to patient knowledge, propose a representation of patient knowledge types across the continuum of care, and include illustrative vignettes about Mr. Jones. We highlight how the field of human factors (a core competency of health informatics) provides a perspective and methods for eliciting and characterizing patient knowledge. Conclusion  Patients play a vital role in the clinical information space by possessing and sharing unique knowledge relevant to the clinical picture. Without a patient''s contributions, the clinical picture of the patient is incomplete. A human factors perspective informs patient-centered care and health information technology solutions to support clinical information sharing.     

Common origin of inferior mesenteric and main renal artery

The first case of a common origin of both the inferior mesenteric and single main renal artery, angiographically documented in a patient with primary ipsilateral ectopic kidney, is reported. Embryologic as well as surgical aspects are mentioned.     

Sonoelasticity of organs: shear waves ring a bell.

Sonoelasticity is the use of ultrasonography to visualize, in real time, the hardness of stiffness of tissues and organs by depicting the tissue's motion in response to an applied vibration source. The applied vibration source is usually of low amplitude and low frequency (less than 0.1 mm displacement and less than 2000 Hz). Under these conditions, the natural vibration response of tissues and whole organs is revealed as a standing wave pattern determined by the low-frequency elastic constants of the tissues and their boundary conditions, factors that are not related to the ultrasonic echogenicity. As a result, hard or dense isoechoic tumors that are undetectable by conventional ultrasonography often can be visualized in sonoelasticity imaging by virtue of their altered vibration response. In this report, we demonstrate the appearance of organs such as the breast, liver, and kidney during real-time, in vivo sonoelasticity imaging. The results show that the shape and location of vibration patterns are dependent on the tissues and vibration frequencies; thus, information about the basic elastic properties of tissues should be obtainable.     

Pitfall in diagnosis of Crohn's disease in a cystic fibrosis patient

Cystic fibrosis (CF) and Crohn's disease may both present as failure to thrive and recurrent intestinal obstruction. Proper treatment and adequate nutrition may reverse these manifestations and improve the patient's quality of life. We describe a girl with CF who, despite appropriate management, failed to grow and had several episodes of bowel obstruction. After the additional diagnosis of Crohn's disease was reached, the patient improved on antiinflammatory and nutritional therapy. This patient illustrates the pitfall in the diagnosis of Crohn's disease in a CF patient due to the clinical overlap between the two conditions. We suggest that therapeutic failure in a chronic disease justifies additional diagnostic efforts resulting in a completion of diagnosis and significant changes in management.     

A comparison of pregnancy outcome in overweight and normal weight women

From a population of singleton pregnancies, 152 overweight women (greater than 110% of standard) were matched with normal weight women (95-110%) for age, height, parity, race, and smoking habits. Comparisons were made of initial weight (weight at the first prenatal visit) and gestational weight gain and pregnancy outcome. Mean birth weights and gestational ages of infants of normal and overweight women were not significantly different. For normal weight women birth weight increased significantly as height, initial weight, and body mas index increased (p less than 0.01), but no such relationship existed for overweight women. The lack of effect of initial weight on birth weight in overweight women is attributable, in part, to the significantly less gestational weight gains of these mothers (6.3 kg vs 8.2 kg). When normal and overweight gravida had gestational weight gains of less than 7 kg, offspring of overweight mothers were significantly heavier. Gestational weight gain was positively correlated with birth weight for both normal (p less than 0.0001) and overweight women (p less than 0.001). Within the overweight and normal weight groups, smokers had lower initial weights and gestational weight gains than nonsmokers. Offspring of normal weight smokers had a mean birth weight 232 g less than that of nonsmokers (p less than 0.01). The difference in birth weight between overweight smokers and nonsmokers (135 g) was not statistically significant. While there is substantial data to support a weight gain of 10-12 kg in normal weight gravida, it would appear that a gain of approximately 7 kg in overweight middle class women does not impair fetal growth as measured by birth weight.(ABSTRACT TRUNCATED AT 250 WORDS)     

Molecular cloning and sequencing of general odorant-binding proteins GOBP1 and GOBP2 from the tobacco hawk moth Manduca sexta: comparisons with other insect OBPs and their signal peptides.

Odorant-binding proteins (OBPs) are small, water-soluble proteins uniquely expressed in olfactory tissue of insects and vertebrates. OBPs are present in the aqueous fluid surrounding olfactory sensory dendrites and are thought to aid in the capture and transport of hydrophobic odorants into and through this fluid. OBPs may represent the initial biochemical recognition step in olfaction, because they transport odorants to the receptor neurons. Insect OBPs are represented by multiple classes: pheromone-binding proteins (PBPs) and general odorant-binding proteins (GOBP1 and GOBP2). PBPs associate with pheromone-sensitive neurons, while GOBPs associate with general odorant-sensitive neurons. Analysis of N-terminal amino acid sequences of 14 insect OBPs isolated from six species indicated that the PBPs were variable and the GOBPs were highly conserved. However, inferred properties of these proteins were based only on partial sequence data. We now report the full-length sequences of a GOBP1 and GOBP2 from the moth Manduca sexta and compare these sequences with those of PBPs from three species, including M. sexta, Antheraea polyphemus, and A. pernyi. We also compare these with a GOBP2 of A. pernyi, previously identified only as a novel OBP. These comparisons fully support our N-terminal analysis. The signal peptide sequences of seven insect OBPs reveal conserved sequences within OBP classes, but not between OBP classes even within the same animal species. This suggests that multiple OBPs may be coexpressed in the same cell type, but differentially processed in a class-specific manner. Properties of the GOBPs suggest that general olfaction is broadly receptive at the periphery. Properties of the PBPs suggest that pheromone olfaction is discriminatory at the periphery, and that the initial biochemical steps in pheromone detection may play an active role in odor perception.     

Increased expression of CD152 (CTLA-4) by normal T lymphocytes in untreated patients with B-cell chronic lymphocytic leukemia.

Patients with chronic lymphocytic leukemia (CLL) have defects in both cellular and humoral immunity. Since CD152 (CTLA-4) plays a critical role in downregulating T-cell responses, we studied the expression of surface and cytoplasmic CD152 (sCD152 and cCD152, respectively) in freshly isolated T cells from treatment-na?ve patients with CLL. CD4+ and CD8+ T cells from these patients demonstrated significantly increased sCD152 and cCD152 compared to normal donors. Furthermore, these patients had an increased proportion of the regulatory CD4(+)/CD25(+)/CD152+ subset that correlated with advanced Rai stage, unfavorable cytogenetics and low serum IgG and IgA levels. The expression of sCD152 by T cells also correlated with ZAP-70 expression by CLL B cells. The proportion of CD4(+)/CD25+ cells was also correlated with unmutated immunoglobulin heavy chain variable gene status. Blockade of CD152 with monoclonal antibody (mAb) in proliferation assays was associated with potent T-cell proliferation in response to autologous and allogeneic CD40-activated CLL B cells. In summary, T cells from patients with CLL may be primed for anergy by expressing increased amounts of CD152; anti-CD152 mAb may represent a therapeutic opportunity to enhance an immune response against autologous leukemia cells.     

Ambulatory Mental Health Treatment under Universal Coverage: Policy Insights from Israel

Untested assumptions concerning ambulatory treatment have shaped mental health policies for decades. Three opinions prevail: (1) all use is alike; (2) any use leads to high use; and (3) all high use is discretionary and therefore excessive. These assumptions were tested, using data from a nationwide survey of ambulatory utilizers in Israel, a country that has universal coverage. The findings, based on detailed clinical and treatment records, challenge all three assumptions. Moreover, they document a diversity of clinical needs while also verifying substantial variations in the type, frequency, and duration of treatment provided to meet those needs. In brief, Israeli data do not confirm continuing concerns by policy makers about uncontrollable use of services with expanded mental health coverage. Special policy limitations on mental health treatment should be reconsidered in light of empirical evidence from a system without the restrictions that exist in the United States.