Towards a Personal Health Management Assistant.

We describe design and prototyping efforts for a Personal Health Management Assistant for heart failure patients as part of Project HealthDesign. An assistant is more than simply an application. An assistant understands what its users need to do, interacts naturally with them, reacts to what they say and do, and is proactive in helping them manage their health. In this project, we focused on heart failure, which is not only a prevalent and economically significant disease, but also one that is very amenable to self-care. Working with patients, and building on our prior experience with conversational assistants, we designed and developed a prototype system that helps heart failure patients record objective and subjective observations using spoken natural language conversation. Our experience suggests that it is feasible to build such systems and that patients would use them. The system is designed to support rapid application to other self-care settings.

El profesor docente y la ética institucional / The educational teacher and the institutional ethics

Organizations develop codes of ethics to give orientations to their members on how to recognize, understand and handle ethical dilemmas in their daily work. In year 2005 a group of faculty members of the Universidad de Chile Faculty of Medicine started an institutional ethics project, acknowledging that all institutional decisions have moral contents. The purpose of this project is to promote an ethical environment in the institution. The first step was to establish a diagnosis by means of the organization of focal groups that collected the perceptions of students, faculty members and non-academic personnel. With a diagnosis in hand, a preliminary document was prepared, the “Universidad de Chile Faculty of Medicine declaration of principles and values”. Members of all groups that participated in the diagnostic phase had the opportunity to discuss this preliminary document and check if their agreement with its contents. Given the relevance of the ethical aspects of the learning and teaching process for the positive modeling of students from all health-related professions, special emphasis is given to its discussion.

Is home health technology adequate for proactive self-care?

OBJECTIVE: To understand whether home health technology in the market and in development can satisfy the needs of patients and their non-professional caregivers for proactive support in managing health and chronic conditions in the home. METHODS: A panel of clinical providers and technology researchers was assembled to examine whether home health technology addresses consumer-defined requirements for self-care devices. A lexicon of home care and self-care technology terms was then created. A global survey of home health technology for patients with heart disease and dementia was conducted. The 254 items identified were categorized by conditions treated, primary user, function, and purpose. A focus group of patients and caregivers was convened to describe their expectations of self-care technology. Items identified in the database were then assessed for these attributes. RESULTS: Patients and family caregivers indicated a need for intelligent self-care technology which supports early diagnosis of health changes, intervention enablement, and improvement of communication quality among patients and the health care system. Of these, only intervention enablement was commonly found in the home health technology items identified. CONCLUSIONS: An opportunity exists to meet consumer self-care needs through increased research and development in intelligent self-care technology.

[The notion of decision making capacity in medical and legal practice]. / La noción de capacidad de la persona para tomar decisiones, en la práctica médica y legal.

BACKGROUND: The relationship between patients and health professionals emphasizes deliberation and joint decision making, that derives in the informed consent. AIM: To evaluate decision making of patients in health care and to identify the notion of capacity for decision making, according to lawyers and physicians. MATERIAL AND METHODS: A semi-structured interview about procedures to assess decision making capacity was applied to 27 selected physicians and lawyers, considering their experience in this area. A qualitative analysis of answers was performed. RESULTS: Several differences were observed between physicians and lawyers, probably originated in their respective disciplines as well as the context of their professional practice. For physicians the notion of capacity is associated to comprehension of the information, it is not absolute, and it must consider the intellectual maturity of the teenager and the autonomy of the elderly. This evaluation is frequently performed in the clinical interview and standardized protocols do not exist. For lawyers, capacity is established by age and is associated to rights and obligations, as determined by law. When it is assessed by experts, including physicians, it becomes evidence. These professionals assume that experts will use standardized assessment instruments. Capacity has significance in the legal system. CONCLUSIONS: Since there are substantial consequences when a person is deemed incompetent, it is necessary to distinguish between health capacity and legal capacity, and to inverted exclamation markink the informed consent with the fundamental rights of citizens, such as taking decisions about our own health.

La noción de capacidad de la persona para tomar decisiones, en la práctica médica y legal / The notion of decision making capacity in medical and legal practice

Background: The relationship between patients and health professionals emphasizes deliberation and joint decision making, that derives in the informed consent. Aim: To evaluate decision making of patients in health care and to identify the notion of capacity for decision making, according to lawyers and physicians. Material and methods: A semi-structured interview about procedures to assess decision making capacity was applied to 27 selected physicians and lawyers, considering their experience in this area. A qualitative analysis of answers was performed. Results: Several differences were observed between physicians and lawyers, probably originated in their respective disciplines as well as the context of their professional practice. For physicians the notion of capacity is associated to comprehension of the information, it is not absolute, and it must consider the intellectual maturity of the teenager and the autonomy of the elderly. This evaluation is frequently performed in the clinical interview and standardized protocols do not exist. For lawyers, capacity is established by age and is associated to rights and obligations, as determined by law. When it is assessed by experts, including physicians, it becomes evidence. These professionals assume that experts will use standardized assessment instruments. Capacity has significance in the legal system. Conclusions: Since there are substantial consequences when a person is deemed incompetent, it is necessary to distinguish between health capacity and legal capacity, and to ¡ink the informed consent with the fundamental rights of citizens, such as taking decisions about our own health.

El cambio de la práctica médica: desafíos psicosociales para la profesión / The change in medical practice: psycho-social challenges for the profession

This article analyzes important changes in medical practice, focusing in those most deeply perceived by a group of physicians from the Metropolitan Region of Santiago, included in a joint research conducted by the Departments of Psychiatry and Mental Health (East) of the Medical Faculty at the University of Chile and Public Health of the Catholic University of Santiago, during 2003. These are the perceived changes in the relationship between doctors and patients; increased limits in professional autonomy and the fragmentation of medical practice. Reflecting transformations in social relationships in general, they have added new stress and frustrations, as well as new opportunities and rewards to the medical profession. The perceptions identified are commented within the structural determinants of medical practice. These issues call for a refreshing discussion on the values supporting medical professionalism and the concept of profession in itself, in view of the challenges posed by the current social and cultural changes (Rev Méd Chile 2004; 132: 768-72).

Application of TAML catalysts to remove colour from pulp and paper mill effluents.

A TAML catalyst (0.5 microM, 0.23 mg/L of effluent) combined with hydrogen peroxide (6.5 mM, 0.19 g/L of effluent) were capable of permanently removing 46% of the colour from bleach plant effluent (Eop, pine-derived) in one hour at 5,000 L effluent per day. Increasing concentrations to 2 microM catalyst (0.9 mg/L of effluent) and 22 mM peroxide (0.75 g/L of effluent), resulted in removal of 78% of the colour. In addition, 29% of the chlorinated organic material (AOX) was also removed. A laboratory investigation indicated that the oxidative process predominantly removed phenolic structures. The low aromatic content of the effluent meant that the majority of the organic material was not substantially altered during treatment. Thus chemical oxygen demand was essentially unchanged. This technology was able to remediate colour from effluents derived from both softwood (pine) and hardwood (eucalypt). Laboratory studies on catalyst life-time during effluent treatment, demonstrated that activity was maintained for a sufficient period to eliminate all the chromophore available to the active species, but that the catalyst did not survive long enough to be discharged into the receiving environment. Microtox tests showed that catalyst degradation products were not toxic to the receiving environment.

Comparison of seroprevalences of human herpesvirus-6 and -7 in healthy blood donors from nine countries.

BACKGROUND AND OBJECTIVES: The purpose of the study was to register antibody prevalences of HHV-7 in various locations of the world in comparison to the closely related HHV-6. MATERIALS AND METHODS: Sera of healthy blood donors from nine countries in five continents were titered by indirect immunofluorescent assays using HHV-6 infected HSB2 and HHV-7 infected SupT1 cells. RESULTS: Antibody prevalence for HHV-7 is high (75-98%) in practically all countries except for Northern Japan (44%), with no simple correlation to elevated HHV-6 antibody titers. There were regions of low, intermediate and high mean antibody titers against HHV-7 such as 78.5-91.3 for Belgium, Israel, Japan, USA and Australia, 175.4-182.6 for Mexico and Cologne/Germany, and 389.2 for South Africa for which geographic characteristics may be responsible. CONCLUSION: HHV-7, similar to HHV-6, is a widespread human herpesvirus with elevated antibody titers in the healthy human population essentially everywhere. The data warrant further studies to evaluate its possible pathologic potential, preferentially in persons with defective immune responses.

Basal cell carcinoma metastatic to the salivary glands: differential diagnosis in fine-needle aspiration cytology.

A disparate group of salivary gland neoplasms is characterized by small, uniform, hyperchromatic, basaloid cells. This "small blue cell" pattern is most common in non-Warthin's types of monomorphic adenoma, or in adenoid cystic carcinoma. Small cell anaplastic carcinoma (primary or metastatic), metastatic basaloid squamous cell carcinoma, basal cell adenocarcinoma, and metastatic nasopharyngeal carcinoma are rarely encountered but may present a cytologically similar appearance. We report one female and two male patients (median age = 84 yr) with cutaneous-type basal cell carcinoma (BCC) aspirated from metastatic deposits in the parotid (2 cases) or the submandibular (1 case) gland. One was correctly classified at the time of aspiration, based on a previous history of multiple facial BCC. One was interpreted as carcinoma, the previous history being unavailable at the time of FNA. Smears in these two cases show necrosis and rare keratotic cells. The third cases was mistaken for pleomorphic adenoma (PA); the smears showed metachromatic fragments of collagenous tumor stroma that were misinterpreted as the matrix material typical PA. Similar material was identified in the other two cases. When the "small blue cell" pattern is encountered in salivary bland cytology, one should consider BCC, especially if necrosis is identified. The desmoplastic tumor stroma of BCC may mimic the chondroid matrix of PA. Careful consideration of previous history is very important.

Basal cell (monomorphic) and minimally pleomorphic adenomas of the salivary glands. Distinction from the solid (anaplastic) type of adenoid cystic carcinoma in fine-needle aspiration.

Cytologic features of the cell-stroma interface are useful in distinguishing between monomorphic adenomas of the basal cell type and adenoid cystic carcinoma. In basal cell adenomas, the collagenous stroma interdigitates with adjacent cells, whereas in adenoid cystic carcinoma, the two are separated by a sharp smooth border. Furthermore, the stroma of basal cell adenomas can contain rare spindle cells or capillaries, but the cylinders of adenoid cystic carcinoma are acellular. The authors review their experience with five cases of basal cell adenoma, and three cases that were designated "minimally pleomorphic adenomas." The latter group showed the small blue cell pattern of basal cell adenoma at the time of fine-needle aspiration, and histology revealed only small foci of typical pleomorphic adenoma. With the exception of one cystic case, the cell-stroma interface of basal cell adenoma was observed in all eight cases. These cases are contrasted with three adenoid cystic carcinomas with extensive solid (anaplastic) areas. All showed the small blue cell pattern and cell-stroma interface features of basal cell adenoma. Neither showed the smooth-bordered cylinders of adenoid cystic carcinoma. Two of these three were incorrectly interpreted as benign at the time of fine-needle aspiration. The authors suggest that the stroma aspirated from solid adenoid cystic carcinoma represents desmoplastic tumor stroma that mimics the pattern of basal cell adenoma in smear material. Distinction between basal cell adenoma and the solid type of adenoid cystic carcinoma at the time of fine-needle aspiration remains a very difficult problem.

Diagnostic difficulties in the interpretation of needle aspiration material from large renal cysts.

In recent years, fine-needle-aspiration biopsies (FNA) have been widely used in the evaluation of renal masses, with false-positive FNA data being very uncommon. We present a case report of a 76-yr-old man with a 16-cm renal cyst and what was interpreted as an isolated calcified mural nodule. Following drainage of the main cyst fluid, FNA biopsy showed atypical cell clusters thought to be positive for malignancy. Subsequent surgery failed to disclose either a residual mural nodule or evidence of malignancy. Immunoperoxidase studies performed on both the cell block and actual cyst wall suggested that the abnormal cells were histiocytes. The diagnostic pitfalls of this case, along with a review of pertinent literature, are discussed.

Infectious mononucleosis in lymphoid tissue. Histopathology, in situ hybridization, and differential diagnosis.

The histopathologic features of tissue specimens from 16 patients with acute Epstein-Barr virus-induced infectious mononucleosis, which was confirmed by clinical and serologic methods, are described. The clinical course was usually self-limited (14 patients), but it resulted in the death of two patients, one of whom (patient with renal transplantation) was immunosuppressed. Each lymphoid tissue specimen, including those obtained from the lymph nodes (n = 9), tonsils (n = 5), spleen (n = 1), and appendix (n = 1), showed a nonuniform expansion of nonfollicular areas by a polymorphous population of lymphocytes, including transformed lymphocytes and immunoblasts. In situ hybridization demonstrated Epstein-Barr virus-infected lymphocytes in four of eight tissue specimens that were studied. Other histologic features included Reed-Sternberg-like cells, plasma cells, histiocytes, frequent mitoses, abundance of postcapillary venules, and necrosis. These histologic features should suggest a diagnosis of infectious mononucleosis rather than other processes, either benign or malignant, that can mimic it.

Nodular fasciitis: spontaneous resolution following diagnosis by fine-needle aspiration.

Nodular fasciitis can be histologically mistaken for a sarcoma. Typical cases are less than 5 cm and enlarge rapidly over days or weeks before diagnosis. The natural history of nodular fasciitis is unknown, since the diagnosis is usually based on excised lesions. Fine-needle aspiration of nodular fasciitis has been described, and features benign-appearing spindle cells (singly and in groups), collagen, and myxoid material. We describe 11 cases in which nonsurgical observation led spontaneously to complete resolution. Our study includes 7 males and 4 females (24 to 73 years of age; median = 42). Lesions were located in the arm (4), thigh (3), temporal area (2), breast (1) and the parotid (1) and ranged from 0.5 to 5.0 cm. (median = 1.5). They had been present for from less than 1 to 4 weeks (median = 2). In 9 cases, spontaneous resolution occurred in from 3 to 8 weeks (median = 4). Two other patients were lost to follow-up for up to 11 months, after which resolution was noted. Small palpable masses in the subcutaneous soft tissues which evolve over a short period of time and show the cytologic features of nodular fasciitis should be managed nonsurgically. If resolution does not occur within a few weeks, surgery can then be performed.

El efecto del cambio social en la familia y en el desarrollo de los adolescentes / The effect of the social change in the family and in the development of the adolescents

Este trabajo ha analizado algunos importantes cambios sociales que están relacionados con la familia. Además se ha descrito de qué forma estos cambios afectan el desarrollo de los hijos adolescentes, cuáles son las consecuencias para su conducta social. Para estos propósitos se han revisado los aportes de seleccionadas investigaciones recientes realizadas en Chile, Estados Unidos y algunos países europeos. Desde un punto de vista ecológico de la familia y del desarrollo humano, que postula la estrecha vinculación de estos procesos con los acontecimientos del contexto, se hace evidente que para las familias de estrato socioeconómico bajo, los condicionantes más decisivos son los impuestos por la pobreza y sus consecuencias. En el caso de las familias de estratos más altos los principales cambios han sido de tipo demográfico: una reducción en su tamaño promedio, el cambio en el rol de la mujer y madre, el aumento de las separaciones matrimoniales. En el caso de las familias pobres, la importancia de las carencias tamiza la influencia de este tipo de variables de orden demográfico sobre el desarrollo de los hijos adolescentes y de todas las edades. No está demostrado, en suma, que la familia reducida esté más desprotegida que una con mayor número de integrantes, en similares condiciones de pobreza. Evidencias documentadas por estudios como los descritos, permiten fundamentar la cuidadosa planificación y desarrollo de intervenciones de tipo preventivo específico, dirigido, por ejemplo, a adolescentes hijos de familias con problemas, con padres alcohólicos, separados o con antecedentes de psicopatología. También señalan sólidamente la necesidad de políticas de protección a la familia, desde los sectores público y privado para promover su desarrollo sano

Granulomatous prostatitis: a spectrum including nonspecific, infectious, and spindle cell lesions.

Most granulomas of the prostate are nonspecific; infectious, post-operative, and allergic lesions are much less common. Fine-needle aspiration findings in the typical case are distinctive and easily recognized. Several series have been reported, but few have included histologic follow-up. We describe three cases of granulomatous prostatitis (GP) which showed a spectrum of findings confirmed by histologic sections. In all cases, carcinoma was suspected clinically. Case 1 represents typical nonspecific GP with epithelioid and multinucleated histiocytes. In case 2, aggregates of epithelioid histiocytes alternated with areas of necrosis and neutrophils. Histologically, the granulomas showed purulent centers. Silver stains revealed budding yeast in smears and sections. Cultures of FNA material subsequently revealed Cryptococcus. In case 3, the histiocytes were predominantly spindled and occurred singly and in groups. The differential diagnosis included reactive and neoplastic spindle cell lesions. Histologic sections showed GP with spindled histiocytes. Appreciation of the broad cytologic spectrum of GP will facilitate accurate cytologic diagnosis.

Cellular follicular cyst of the ovary: fluid cytology mimicking malignancy.

We report three ovarian cysts studied by aspiration cytology. The fluids obtained were highly cellular, with numerous groups of atypical cells featuring a high nuclear-cytoplasmic ratio, nuclear hyperchromasia, and prominent nucleoli. In each case, these features were considered evidence of a low-grade malignant neoplasm. All three patients underwent oophorectomy, which revealed benign follicular cysts. Possible means of resolving the diagnostic dilemma posed by these cellular follicular cysts are discussed.