A knowledge-based patient assessment system: conceptual and technical design.

This paper describes the design of an inpatient patient assessment application that captures nursing assessment data using a wireless laptop computer. The primary aim of this system is to capture structured information for facilitating decision support and quality monitoring. The system also aims to improve efficiency of recording patient assessments, reduce costs, and improve discharge planning and early identification of patient learning needs. Object-oriented methods were used to elicit functional requirements and to model the proposed system. A tools-based development approach is being used to facilitate rapid development and easy modification of assessment items and rules for decision support. Criteria for evaluation include perceived utility by clinician users, validity of decision support rules, time spent recording assessments, and perceived utility of aggregate reports for quality monitoring.

Laparoscopic and percutaneous radiofrequency ablation of the kidney: acute and chronic porcine study.

OBJECTIVES: The chronic effects of renal radiofrequency ablation are unknown. Herein, we investigate the anatomic and physiologic sequelae of laparoscopic and percutaneous renal radiofrequency ablation in acute and chronic porcine models. METHODS: Our study comprised two phases-an acute phase and a chronic phase. In the acute phase, bilateral laparoscopic renal radiofrequency ablation was performed in 6 animals (12 renal units), which were euthanized immediately after surgery. In the chronic study, bilateral percutaneous renal radiofrequency ablation was performed in 5 animals (10 renal units). One animal each was euthanized at postoperative day 3, 7, 14, 30, and 90. RESULTS: Ultrasound-monitored laparoscopic (n = 12) and percutaneous (n = 10) radiofrequency ablations of the lower pole of the kidney were technically successful in each instance. No intraoperative complications occurred. In the survival experiments, the radiolesions showed gradual spontaneous resorption and ultimate renal autoamputation, while maintaining pelvocalyceal integrity as confirmed by ex vivo retrograde ureteropyelogram. Serum creatinine and hematocrit remained stable in all survival animals. Postoperative complication occurred in 1 chronic animal with nonobstructive small bowel dilation at autopsy. CONCLUSIONS: Laparoscopic and percutaneous renal radiofrequency ablation are technically feasible. The anatomic and physiologic sequelae of renal radiosurgery are favorable. Improved techniques of real-time monitoring of the evolving renal radiolesion are necessary.

A novel gastrin-binding protein in the human eosinophil.

A specific and saturable interaction between 125I-gastrin and eosinophils was discovered in autoradiographs of human gastric mucosal tissue and confirmed in isolated and enriched preparations of WBC's. Gastrin displaced 125I-gastrin from eosinophils in a dose-dependent manner with a D50 = 11 uM. Scatchard analysis of the saturation curve indicated a single binding site of low affinity (Kd = 4.14 uM) and high capacity (Bmax = 430 umoles/mg protein). The gastrin binding protein was localized to the granular core of the eosinophil and found to have a molecular weight of approximately 15 kDa following chemical crosslinking of radioligand to granules and SDS/PAGE. Based on its molecular weight and granular location and the charge characteristics of gastrin, the gastrin binding protein in the human eosinophil is most likely major basic protein. In vivo this interaction might act to limit the cytotoxic potential of MBP on tissues and/or attentuate gastrin concentrations thereby helping regulate gastric acid secretion and mucosal growth.

P-CAPE: a high-level tool for entering and processing clinical practice guidelines. Partners Computerized Algorithm and Editor.

The Partners Computerized Algorithm Processor and Editor (P-CAPE) is a high-level tool intended to remove the programming bottleneck for implementing practice guidelines in our computer-based record system, and to integrate guideline-based advice into the clinician's workflow. P-CAPE has three major components: 1) An Editor that allows an analyst to enter the parameters of a guideline in the form of an algorithm; 2) A Navigator that processes the steps of the guideline and logs all transactions in a patient-specific file; and 3) A clinician Notifier that sends messages to a patient's covering clinician, seeking data or presenting recommendations and order sets that can be processed by the system. P-CAPE's guideline object model was adapted from the InterMed Collaboratory GuideLine Interface Format (GLIF).

Thrombotic tendencies and correlation with clinical status in patients infected with HIV.

Previous publications have described thrombotic events with unclear causes in individuals infected with the human immunodeficiency virus (HIV). We stratified the cases of 52 individuals infected with HIV by degree of immunosuppression and the presence of complicating illnesses. Plasma from these individuals was screened for abnormalities that might predispose to thromboses. We found statistically significant differences between patients with CD4 counts < 200/mm3 and those whose CD4 counts were > 400/mm3 in the following: d-dimers, functional protein C, antigenic protein C, total protein S antigen, free protein S antigen, C4b-binding protein (C4b-BP), and von Willebrand antigen (vWD). Free protein S correlated inversely with C4b-BP; vWD directly with total protein S; and protein C inversely with d-dimers. D-dimers were significantly elevated only in immunosuppressed patients with complicating neoplastic/inflammatory disease. We propose that low-grade disseminated intravascular coagulopathy in severely immunosuppressed individuals with HIV and infectious, inflammatory, or neoplastic complications is responsible for depressed protein C, which, together with elevations in total protein S and vWD (markers of endothelial injury), indicates a thrombotic predisposition.

Disseminated histoplasmosis in AIDS patients in Maryland.

These patients demonstrate the difficulty in arriving at the diagnosis of disseminated histoplasmosis. The diagnosis in two of the three patients also served as the initial AIDS case-defining opportunistic infection. In each of these patients, the clinical presentations were atypical and in only one patient was a positive exposure history elicited. Recurrent bowel obstruction was the presenting complaint in the first patient and the diagnosis was made only on pathologic exam of the resected small bowel. The second patient's diagnosis was made on biopsy of the colon via colonoscopy. The third patient's diagnosis also eluded an extensive FUO workup; he was diagnosed by bone marrow culture and silver stain of a mediastinal lymph node biopsy, despite serial negative serologic tests for histoplasmosis. The first two patients had significant gastrointestinal disease which is a relatively unusual manifestation for disseminated histoplasmosis. The third patient illustrates the limited diagnostic usefulness of serologic testing in AIDS patients and the continued usefulness of bone marrow analysis in an FUO evaluation. In conclusion, these case presentations demonstrate that disseminated histoplasmosis in patients with HIV infection can present with unusual manifestations, outside of the typical endemic arca, without a positive exposure history or positive serologic test, and may be the initial AIDS case-defining opportunistic infection in these patients. Consequently, a disseminated histoplasmosis should be considered in all AIDS patients with perplexing clinical presentations.

Acquired protein C deficiency in patients with breast cancer receiving cyclophosphamide, methotrexate, and 5-fluorouracil.

Recent reports have documented an increase of thrombotic complications in patients with carcinoma of the breast receiving chemotherapy regimens containing cyclophosphamide, methotrexate, and 5-fluorouracil. The authors studied blood from nine such patients screening for abnormalities that might predispose to thrombosis or indicate that the coagulation cascade had been activated. Six of the patients were in the adjuvant setting, and three had metastatic disease. Samples were collected from each patient before, during, and after completion of the chemotherapy in question. In each patient a statistically significant decline in functional protein C activity (P = 0.001) was demonstrated at midtherapy. In seven of nine patients functional protein C level normalized after the cessation of therapy. No other positive results were found. The authors conclude that the combination of cyclophosphamide, methotrexate, and 5-fluorouracil, when administered to patients with a diagnosis of carcinoma of the breast, causes a reversible decline in the activity of protein C.

Documentation of clinical interactions: quality of care issues and economic considerations in critical care pharmacy.

Pharmacists employed in the critical care area in a 350 bed, community-based, Class II trauma facility demonstrated cost savings through documentation of clinical interactions. Data collection took place between January 1, 1986 and December 31, 1986. Four areas of potential cost savings to the hospital were identified: 1) interactions that resulted in drug cost avoidance of $26,580 per year; 2) detection of excessive doses, toxic serum concentrations and electrolyte imbalances resulting in maximizing quality drug therapy; 3) unnecessary or inappropriate laboratory tests, which avoided $3930 in patient charges due to 80 fewer tests; 4) reduced inventory from the critical care area allowing $5209 in medication to be relocated. Under current prospective reimbursement programs, cost containment and quality care are of primary concern for pharmacy departments. The presence of a critical care satellite staffed by qualified pharmacists can provide these measures.

Interaction of vesicular-arbuscular mycorrhizal fungi with erosion in an oxisol.

The development of vesicular-arbuscular mycorrhizal (VAM) symbiosis was monitored in Leucaena leucocephala grown in an Oxisol subjected to incremental simulated erosion. The density of VAM infective propagules in the soil diminished as the level of simulated erosion (removal of surface soil) was increased from 0 to 50 cm. The level of infection on L. leucocephala roots observed at harvest was not significantly influenced by simulated erosion unless removal of surface soil exceeded 25 cm. Inoculation of this soil and the uneroded soil with Glomus aggregatum enhanced the early onset of infection but did not significantly influence the level of infection observed at the time of harvest. Simulated erosion in excess of 7.5 cm of surface soil removal significantly delayed the development of VAM effectiveness monitored in terms of the P status of L. leucocephala subleaflets and also curtailed the level of maximum effectiveness observed. Decreases in VAM effectiveness were significantly correlated with decreases in soil chemical constituents. However, VAM effectiveness in a soil subjected to 30 cm of surface soil removal was not restored to a significant extent unless the soil was amended with P, even though other nutrients were restored to sufficiency levels. Our results demonstrate that the development of VAM effectiveness is the phase of the VAM symbiosis that is most adversely influenced by simulated erosion and that this effect appears to be caused primarily by insufficient P in the soil solution.

Platelet aggregability in rats with early atherosclerotic changes induced by parenterally-administered lipid emulsions.

The present study is the first work to evaluate thrombin-, ADP-, and collagen-induced platelet aggregation in laboratory rats receiving alimentation with the parenterally-administered lipid emulsion, Lipofundin-S, in doses sufficient to induce early atherosclerotic changes in the aorta. The aggregometry parameters of percent maximum aggregation, slope, and b2 or b20 almost uniformly indicate that such lipid treatments result in a statistically significant increased sensitivity of the platelets to ADP and collagen, while no change is noted with thrombin as the aggregating agent. By varying the amounts of ADP and collagen during aggregometry, we also demonstrate that the concentrations of these reagents necessary for equivalent platelet aggregation is substantially lower in lipid-infused rats than in controls. We conclude from this study that such lipid infusions can cause increased platelet aggregation, and that these lipids probably act in a synergistic fashion by affecting a variety of components which comprise the atherogenic process and its clinical endpoint. In addition, we believe that this experimental approach is of interest in that infusions of clinically-useful lipid emulsions are easily controlled, while alterations in platelet physiology and aortic structure occur concurrently and rapidly.

Adventitial cystic disease of the popliteal artery: failure of percutaneous transluminal angioplasty as a therapeutic modality.

Adventitial cystic disease of the popliteal artery is an important cause of peripheral vascular insufficiency in the young and middle-aged man. The pathologic feature is a mucinous cyst located within the adventitia of the artery that expands and secondarily compromises the vessel lumen. Although physiologically quite different, this process is easily mistaken for arteriosclerosis. The clinical history of sudden claudication in a young nonsmoking man, combined with characteristic angiographic features, are important clues to the correct underlying pathology. Treatment generally consists of cyst evacuation or local bypass. This article was prompted by the failure of percutaneous transluminal angioplasty to achieve durable success in controlling this unique type of arterial disease. Subsequent surgical intervention proved satisfactory, lending support to this modality as the treatment of choice.

Audiological investigation of palatal myoclonus.

Palatal myoclonus, the rapid rhythmic contraction of palatal muscles, is a rare neurological disorder with many etiologies. Although most disease processes associated with this disorder affect the cerebellum, the auditory symptoms are often the first clue to diagnosis. Existing literature was reviewed in terms of auditory symptoms, pathophysiology, audiologic diagnostic procedures and rehabilitative strategies. In addition, a case study of a 34-yr-old woman who has had this highly peculiar degenerative disorder for over 20 yrs was described. Implications for appropriate rehabilitation strategies were addressed and the importance of comprehensive management was stressed.

Characterization of a monoclonal antibody that reacts with activated/proliferating cells and subsets of leukemia cells.

This report describes a murine IgG2A monoclonal antibody, called L22, derived by immunizations with an Epstein-Barr virus-negative large cell lymphoma B cell line. The antigen detected by L22 is not present on normal peripheral blood cells, but is present on cells stimulated by various mitogens. The proportion of L22+ cells correlates closely with blastogenesis and 125I-uridine uptake. L22 precipitates a 89,500-dalton antigen under reducing conditions, and a 180,000-dalton antigen under nonreducing conditions. The immunoreactivity, molecular weight of the antigen, sequential immunodepletion, and blocking experiments suggest that L22 reacts with the transferrin receptor, although it did not specifically block transferrin. L22 reacts with a variable proportion of cells from virtually all human myeloid, lymphoid, and solid tumor cell lines tested. Expression of the antigen is relatively constant within a given cell line and varies to only a limited extent with DNA content or cell cycle. The antigen has been identified on rare lymph node cells in certain reactive and malignant conditions. The antibody reacts with a variable number of peripheral blood cells in certain cases of myeloid and lymphoid leukemias, but does not react with peripheral lymphocytes from patients with inflammatory conditions. Its reactivity suggests possible utility in subclassification of leukemias, and perhaps in immunotherapy, in view of the limited reactivity with nonproliferating cells.

Interlocking twins. Experience with four cases and suggested management.

Experience with the management of 4 pairs of locked twins is described and analyzed. In view of the high morbidity figures a proposed preemptive management is suggested.