Confronting and resolving an ethical dilemma associated with a practice based evaluation using observational methodology of health information technology.

SUMMARY: As the adoption of health information technology (HIT) has escalated, efforts to evaluate its uptake have increased. The evaluation of HIT often requires direct observation of health care practitioners interacting with the system. When in the field, the evaluator who is not a trained health care provider may observe suboptimal use of the technology. If evaluators have plans to share the results of the evaluation at the conclusion of the study, they face a decision point about whether to disclose interim results and the implications of doing so. To provide HIT evaluators with guidance about what issues to weigh when observing the implementation of HIT, this paper presents a study of an actual case and discusses the following considerations: (1) whether the evaluation of HIT is considered to be human subject research; (2) if the evaluation is human subject research, whether the Institutional Review Board will consider it exempt from review or subjected to expedited or full review; and (3) how interim disclosure to the clinic management impacts the research study. The recommendations to evaluators include use of a protocol for interim disclosures to patients, clinicians, and/or clinical management for both quality assurance initiatives and human subjects research.

Telomeres in the chicken: genome stability and chromosome ends.

Telomeres are the complex nucleoprotein structures at the termini of linear chromosomes. Telomeric DNA consists of a highly conserved hexanucleotide arranged in tandem repeats. Telomerase, a ribonucleoprotein of the reverse transcriptase family, specifies the sequence of telomeric DNA and maintains telomere array length. Numerous studies in model organisms established the significance of telomere structure and function in regulating genome stability, cellular aging, and oncogenesis. Our overall research objectives are to understand the organization of the telomere arrays in chicken in the context of the unusual organization and specialized features of this higher vertebrate genome (which include a compact genome, numerous microchromosomes, and high recombination rate) and to elucidate the role telomeres play in genome stability impacting cell function and life span. Recent studies found that the chicken genome contains three overlapping size classes of telomere arrays that differ in location and age-related stability: Class I 0.5 to 10 kb, Class II 10 to 40 kb, and Class III 40 kb to 2 Mb. Some notable features of chicken telomere biology are that the chicken genome contains ten times more telomeric DNA than the human genome and the Class III telomere arrays are the largest described for any vertebrate species. In vivo, chicken telomeres (Class II) shorten in an age-related fashion and telomerase activity is high in early stage embryos and developing organs but down-regulates during late embryogenesis or postnatally in most somatic tissues. In vitro, chicken cells down-regulate telomerase activity unless transformed. Knowledge of chicken telomere biology contributes information relevant to present and future biotechnology applications of chickens in vivo and chicken cells in vitro.

Is the donut in front of the car? An electrophysiological study examining spatial reference frame processing.

The process of describing an object's location relative to another object results in ambiguity. How do people handle this ambiguity? The present studies examined spatial language processing when use of different reference frames results in ambiguity. We investigated whether electrophysiological (ERP) measures of cognitive processing may elucidate underlying reference frame processing; in particular, we were interested in semantic integration. ERP results showed a larger N400, peaking between 300 and 375 ms, when the intrinsic frame was not used. Behavioural results mirrored this finding, indicating a reduced cognitive processing requirement for the intrinsic reference frame. Previous work has not definitively tied spatial reference frame processing to specific ERP components and their associated cognitive processes. Although the N400 peak seen in this data is early, additional work supports the N400 interpretation, thereby linking spatial frame processing to semantic integration. Results are discussed within the larger context of spatial reference frame processing.

"Aha" effects in the generation of pictures.

An "aha" effect in memory was first reported by Auble, Franks, and Soraci (1979). They demonstrated that recall was greater for sentences that were initially incomprehensible but which were eventually comprehended, as compared with sentences that were understood from the outset. The present studies extend this "aha" effect to memory for pictorial stimuli. In Experiment 1, a recall advantage for pictures encoded by connecting the dots as compared with those encoded by tracing or visual scanning occurred only in the absence of foreknowledge of the picture (i.e., an "aha" effect). In Experiment 2, we replicated this finding and obtained evidence that conceptually based, verbal foreknowledge does not function in a similar manner as does pictorial foreknowledge in suppressing the "aha" recall advantage. These results place important constraints on previous research on generation effects for visual stimuli and attest to the cross-modal generalizability of the "aha" effect.

Not all narrative shifts function equally.

Readers of narratives keep track of narrative events and the information associated with these events. Does some of this associated information help structure the processing of and memory for the narrative? In three experiments, we examined the role of basic event building blocks (character, time, and location) in event indexing during text comprehension. These three experiments dealt with perceived coherence, perceived cohesion, and on-line processing, respectively. The results indicated that characters are more likely to serve as event indexes. Although the findings with respect to indexing were similar in all three experiments, interesting differences emerged as a function of the level of text comprehension examined (coherence, cohesion, or on-line processing).

Treatment of human immunodeficiency virus during pregnancy: the shift from an exclusive focus on fetal protection to a more balanced approach.

A review is presented of policy and treatment guidelines for human immunodeficiency virus infection in pregnancy. Interventions that serve the best interests of pregnant women and their fetuses are suggested. Reproductive studies with animals should be done routinely, and more research with pregnant women should be conducted. Women and their health care providers need to shift away from the "therapeutic nihilism" paradigm. All clinical decisions must be made cautiously and thoughtfully, with the understanding that the health needs of the pregnant woman are usually whatever is in the best interest of the developing fetus.

Rising levels of cardiovascular mortality in Mississippi, 1979-1995.

BACKGROUND: Cardiovascular disease rates are improving in the United States, but not for certain subgroups, especially some African Americans. The objective of the study is to assess current levels and trends in cardiovascular disease mortality in Mississippi. METHODS: Mortality statistics from the U.S. vital statistics system for the period 1979-95 were used. Comparison of age-adjusted mortality rates in Mississippi with the other states for the year 1995 and with the nation as a whole over the period of 1979-95 was performed. RESULTS: Mississippians had the highest age-adjusted cardiovascular disease morality rates in the nation in 1995. Overall, the cardiovascular rates in Mississippi were 37% higher than for the U.S. African American men and women from Mississippi had especially high cardiovascular mortality rates, approximately 50% and 70% higher than their white counterparts, respectively. The higher burden of cardiovascular disease in African Americans from Mississippi was especially marked in the younger age groups. Since about 1984-85, cardiovascular mortality rates in Mississippi have been increasing for African Americans, whereas nationally they have been decreasing. In contrast, cardiovascular mortality rates for whites in Mississippi have been declining, but at a much slower rate than seen nationally. The wide divergence in trends for African American and white men and women over that period in Mississippi has lead to an estimated 19,400 excess cardiovascular deaths. Virtually identical trends were found for heart disease. CONCLUSIONS: Cardiovascular diseases are a major public health problem in Mississippi that is especially severe in African American residents, and the problem is growing worse each year. It is important to identify the determinants of and solutions for this enormous public health problem in Mississippi.

Ontogeny of telomerase in chicken: impact of downregulation on pre- and postnatal telomere length in vivo.

Telomeres are the termini of linear chromosomes composed of tandem repeats of a conserved DNA sequence. Telomerase provides a mechanism for proliferating cells to offset telomeric sequence erosion by synthesizing new repeats onto the end of each parental DNA strand. Reduced or absent telomerase activity can lead to telomere shortening and genome instability. Telomeres and telomerase have not previously been characterized during ontogeny of any avian species. In the present study, telomerase activity in the chicken model was examined from early differentiation embryos through to adulthood. Telomerase activity was detected in all early embryos (preblastula through neurula) and in tissues throughout organogenesis. Subsequently, telomerase was downregulated in the majority of somatic tissues, either pre- or postnatally. A subset of tissues, such as intestine, immune and reproductive organs, exhibited constitutive activity. The impact of telomerase downregulation on telomere length was investigated and a telomere reduction of 3.2 kb in somatic tissues compared with germ line was observed in 5-year-old adults. The present results suggest that the telomere clock function is a conserved feature of avians as well as mammals. Knowledge regarding the relationships among telomerase regulation, proliferation/senescence profiles and differentiation status will be useful for numerous applications of chicken cells.

Sexual activity and the cardiovascular patient: guidelines.

Modern cardiac rehabilitation is a comprehensive program of secondary prevention for patients with heart disease. Moreover, it is an important context in which to broach issues of impaired sexual function. Sexual problems plague a large portion of our cardiac patient population. Unspoken+ concerns about impotence, now more correctly called erectile dysfunction (ED), are common, as are concerns about the safety of engaging in sexual activity, especially after major cardiac events or therapeutic interventions. A large proportion of patients do not return to normal sexual activity after a cardiac event. Many factors, including normal age-related changes in sexual response, medication-induced dysfunction, and vascular changes associated with risk factors (e.g., diabetes and dyslipidemia), as well as the emotional impact of symptomatic heart disease, may influence sexual function in these patients. These factors, occurring alone or in combination, probably explain the discouraging prevalence of sexual dysfunction in patients with manifest cardiac disease. Because so few patients have specific cardiac reasons for limiting sexual activity, a clear opportunity exists for cardiologists and their staff to help enhance the emotional well-being and overall quality of life of their cardiac patients.

Barriers to informed consent.

OBJECTIVES: To provide oncology nurses with a review of barriers that may limit the ability of adults to provide informed consent. DATA SOURCES: Published articles, research studies, and review articles pertaining to informed consent and clinical research. CONCLUSIONS: Patient-centered barriers to informed consent (such as age, education, and illness) and process-centered barriers (such as content and readability of the consent form, timing of discussion, and amount of time allotted to the process) can affect an individual's ability to provide substantial informed consent. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses must be aware and knowledgeable of the various barriers to informed consent to minimize these barriers and to improve and facilitate the informed consent process.

Goal-specific influences on the representation of spatial perspective.

In two experiments, subjects learned an unfamiliar campus environment, either by studying a map or by navigating. During acquisition, the subjects had one of two spatial goals: to learn the layout of the building (survey goal) or to learn the fastest routes between locations (route goal). Spatial memory was tested with several tasks, some assessing survey perspective processing and some assessing route perspective processing. Results indicate multiple influences on the representation of spatial perspective. Learning condition influenced performance. Individuals studying maps gave more accurate responses to some survey perspective tasks, whereas individuals navigating gave more accurate responses to some route perspective tasks. Spatial goals also influenced performance. Having a route goal enhanced performance on route perspective tasks; having a survey goal enhanced performance on survey perspective tasks. These findings are discussed in the context of research indicating flexibility when processing spatial perspective. Individuals can use spatial information from different perspectives, often doing so in a goal-directed manner.

Relationship among mental stress-induced ischemia and ischemia during daily life and during exercise: the Psychophysiologic Investigations of Myocardial Ischemia (PIMI) study.

OBJECTIVES: The purposes of this database study were to determine: 1) the relationship between mental stress-induced ischemia and ischemia during daily life and during exercise; 2) whether patients who exhibited daily life ischemia experienced greater hemodynamic and catecholamine responses to mental or physical stress than patients who did not exhibit daily life ischemia, and 3) whether patients who experienced daily life ischemia could be identified on the basis of laboratory-induced ischemia using mental or exercise stress testing. BACKGROUND: The relationships between mental stress-induced ischemia in the laboratory and ischemia during daily life and during exercise are unclear. METHODS: One hundred ninety-six stable patients with documented coronary disease and a positive exercise test underwent mental stress testing and bicycle exercise testing. Radionuclide ventriculography and electrocardiographic (ECG) monitoring were performed during the mental stress and bicycle tests. Patients underwent 48 h of ambulatory ECG monitoring. Hemodynamic and catecholamine responses were obtained during mental stress and bicycle tests. RESULTS: Ischemia (reversible left ventricular dysfunction or ST segment depression > or = 1 mm) developed in 106 of 183 patients (58%) during the mental stress test. There were no significant differences in clinical characteristics of patients with, compared with those without, mental stress-induced ischemia. Patients with mental stress ischemia more often had daily life ischemia than patients without mental stress ischemia, but their exercise tests were similar. Patients with daily life ischemia had higher ejection fraction and cardiac output, and lower systemic vascular resistance during mental stress than patients without daily life ischemia. Blood pressure and catecholamine levels at rest and during the mental stress tests were not different in patients with, compared with those without, daily life ischemia. Patients with daily life ischemia had a higher ejection fraction at rest and at peak bicycle exercise compared with patients without daily life ischemia, but there were no other differences in peak hemodynamic or catecholamine responses to exercise. The presence of ST segment depression during routine daily activities was best predicted by ST segment depression during mental or bicycle exercise stress, although ST segment depression was rare during mental stress. CONCLUSIONS: Patients with daily life ischemia exhibit a heightened generalized response to mental stress. ST segment depression in response to mental or exercise stress is more predictive of ST segment depression during routine daily activities than other laboratory-based ischemic markers. Therapeutic management strategies might therefore focus on patients with these physiologic responses to stress and on whether lessening such responses reduces ischemia.

Presenting characteristics, treatment patterns, and clinical outcomes of non-black minorities in the National Registry of Myocardial Infarction 2.

Data from a national registry (cohort) of myocardial infarction, which has enrolled 275,046 patients from June 1994 to April 1996, were analyzed to compare the baseline demographic and clinical characteristics, treatment patterns, and clinical outcomes among Hispanics, Asian-Pacific islanders, and native Americans with those of white Americans presenting to the hospital with acute myocardial infarction. Non-black minorities were younger, had a higher proportion of men, used the emergency medical services less frequently, and presented later to the hospital after the onset of symptoms (135 vs 122 minutes, p <0.001) than whites. Also, non-black minorities were less likely to receive beta-blocker therapy at discharge (crude odds ratio 0.86, confidence interval 0.82 to 0.90) than whites, but they were generally as likely to receive intravenous thrombolytic therapy (with the exception of Asian-Pacific islanders) and undergo both coronary arteriography and revascularization procedures as their white counterparts. There were no significant differences in hospital mortality for non-black minorities compared with whites.

Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators.

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p <0.001), were more likely to have atypical cardiac symptoms (28% vs 24%, p <0.001), and nondiagnostic electrocardiograms during the initial evaluation period compared with whites (37% vs 31%, p <0.001). Also, blacks were less likely to receive intravenous thrombolytic therapy (adjusted odds ratio [OR] 0.76, 95% confidence intervals [CI] 0.71 to 0.80), coronary arteriography (adjusted OR 0.85, 95% CI 0.77 to 0.95), other elective catheter-based procedures (adjusted OR 0.87, 95% CI 0.78 to 0.96), and coronary artery bypass surgery (adjusted OR 0.66, 95% CI 0.58 to 0.75) than their white counterparts. Despite these differences in treatment, there were no significant differences in hospital mortality between blacks and whites.

Ethnic disparities in patient recall of physician recommendations of diagnostic and treatment procedures for coronary disease.

Despite the proven benefits of many cardiac procedures, some are used less frequently for African Americans than for white patients with known or suspected coronary disease. This study explored differences between ethnic groups that may affect patient recall of physician recommendations of cardiac procedures. Also examined were patients' responses when asked about adhering to those recommendations. The data examined were collected from interviews with 1,333 African American and white hospital inpatients with known coronary disease admitted to the Birmingham-Black Health Seeking for Coronary Heart Disease Project (1989-1990) in Alabama. Respondents were asked to recall previous health care encounters, physician recommendations of cardiac procedures, and adherence to those recommendations. Compared with whites, fewer African American patients recalled physicians recommending some cardiac procedures. If procedure recommendations were recalled, no ethnic differences were found in patient recall of adhering to those recommendations. Predictors of recall of the recommended procedures were identified by multivariate logistic regression. Patients' knowledge of having coronary disease was the common factor that predicted their recall of all cardiac procedures. Other predictor variables included some cardiac risk factors and symptoms, socioeconomic status, and ethnicity. Although health care practice is influenced by many factors, it is important to examine variables that may lead to a reduction in ethnic disparities in coronary disease morbidity and mortality.

Constitutional del(19)(q12q13.1) in a three-year-old girl with severe phenotypic abnormalities affecting multiple organ systems.

We present the clinical, cytogenetic, and molecular studies on a constitutional deletion of 19q ascertained prenatally due to decreased fetal activity and IUGR. Chromosome analysis by GTG banding on amniocytes suggested a del(19)(q13.1q13.3), but the analysis of microsatellites by PCR demonstrated that the deletion involved the distal segment of q12 and the proximal segment of q13.1 (15 cM). The severely affected female infant born at 38 weeks has clinical findings that may be related to haploinsufficiency of specific genes within 19q12.1-->q13.1 that control important processes of normal development and cell function.

Maternity care practices of navy family practice residency graduates after leaving the military.

BACKGROUND: Nationwide, 32% of residency-trained family physicians deliver babies compared with 73% to 90% in the military. This study describes and defines issues that could ultimately help revive family practice maternity care. METHOD: We surveyed 112 family physicians who had left the navy. RESULTS: Ninety-one percent had delivered babies in the navy, 45% since leaving the military, and 25% currently. Principal maternity care incentives both in and out of the military were personal and professional satisfaction. Reasons for not providing civilian maternity care included malpractice risks, insurance costs, and lifestyle issues. The decision for providing maternity care was usually made before or during residency, whereas the decision against was most often made upon leaving the military. Among more recent graduates (1990-1995), 48% continued to deliver babies in civilian practice. (This is about 20% more than recent civilian graduates.) Malpractice concerns were less important to this group than to earlier graduates. CONCLUSIONS: Factors discouraging family physicians from providing maternity care arise from their practice environment and are not easily overcome with improved training and experience. Recent navy residency graduates are not as easily discouraged.

Reported comfort with obstetrical emergencies before and after participation in the advanced life support in obstetrics course.

BACKGROUND AND OBJECTIVES: Prior research has demonstrated a change in Advanced Life Support in Obstetrics (ALSO) course attendees' reported comfort with managing specific obstetrical emergencies and procedures before and immediately after participation in an ALSO course. Assessment of longer-term stability of these changes has not been performed. This study measured changes in comfort with obstetrical emergencies and reported practice patterns 1 year after ALSO training. METHODS: ALSO course attendees (275) were given a grounded Likert scale survey measuring reported comfort with the management of specific obstetrical emergencies and procedures before, immediately after, 6 months after, and 1 year after participation in an ALSO course. Practice patterns were also surveyed. Paired data were analyzed using the Kruskal-Wallis one-way ANOVA test at a 95% confidence interval for two-tailed significance. RESULTS: ALSO course participants reported a significant increase in their comfort with the management of each of 15 obstetrical emergencies and procedures taught in the ALSO curriculum. Reported comfort remained high at 6 months' and 1-year follow-up and was accompanied by a statistically significant change in reported practice patterns; more participants performed, in their practice 1 year after completion of ALSO training, amnioinfusion, vacuum-assisted vaginal delivery, and ultrasound for determining fetal position and placental location. CONCLUSIONS: Affective learning is important in translating knowledge and skills into the practice of medicine. Our study demonstrates that participation in the ALSO course increases participants' knowledge in the affective domain of learning.