Pain clinic EPR: requirements determination & configuration.

UNLABELLED: The focus of this study was to determine requirements for a general pain EPR (electronic patient record), design this EPR and develop a prototype for demo purposes in pain clinics in The Netherlands. The specifications for this EPR were derived from the 'Nijmegen Classification of Pain', analysis of patient paper records and in-depth interviews with six anaesthesiologists, three physiotherapists and two psychologists. For development a generic configuration tool was used. The actual EPR consisted of five components (two for the anaesthesiologists, one for the physiotherapist, one for the psychologist and one for the whole team). The five components comprised of numerous dialogues. The medical care process directed these dialogues. CONCLUSIONS: The different organisational settings and the variability in provided patient care compromised the development of an EPR for all pain clinics. Defining the granularity of the dialogues was influenced mainly by the factors mentioned previously. However, most respondents agreed on the importance of the following functional demands: registration speed, security, flexibility and supporting of communication between the care providers.

Towards a more rational use of psychoactive substances in clinical practice.

Complex knowledge and data intensive nature of the psychoactive drug selection and prescription process often makes for irrational and inconsistent use of psychoactive drugs in clinical practice. After describing the state of the art with respect to psychoactive drug prescription practices and selection processes, our aim is to analyze the advantages of computer support systems in assisting the clinician in his clinical decisions. Finally, we will review the neuropsychiatric expert systems developed for the neuropsychiatric domain. Suboptimal psychoactive drug therapy is common practice, which leads to hospital admissions, extended length of hospital stay, ineffective therapy and increased costs. Furthermore, the psychoactive drug selection process is a complex decision process, using up-to-date integrative knowledge of drugs from basic sciences to the clinical level. Due to the information load, the lack of appropriate up-to-date information at the point of clinical care and the problem of integrating and weighing all information relatively equally, it is questionable whether any clinician can manage such a complex situation with optimal effectiveness. As has been shown in a number of experiments, clinicians can benefit from computer-based systems that provide access to accurate, up-to-date information. We maintain that more rational use of psychoactive drugs in clinical practice is needed, and conclude that rational psychoactive drug prescription is a knowledge and data-intensive task requiring true expertise derived from clinical, pathophysiological and pharmacotherapeutic knowledge. We will be developing a Multidisciplinary Psychoactive Drug Selection advisor system, M-PADS, to support the integration of various types of biomedical information and deliver that integrated information supportive to evidence-based rational drug prescription in the practice of medicine for the drug treatment of individual patients.

Progress with formalization in medical informatics?

The prevailing view of medical informatics as a primarily subservient discipline in health care is challenged. Developments in both general informatics and medical informatics are described to identify desirable properties of modeling languages and tools needed to solve key problems in the application field. For progress in medical informatics, it is considered essential to develop far more formal modeling languages, modeling techniques, and tools. A major aim of this development should be to expel ambiguity from concepts essential to medicine, positioning medical informatics "at the heart of health care."

Requirements for medical modeling languages.

OBJECTIVE: The development of tailor-made domain-specific modeling languages is sometimes desirable in medical informatics. Naturally, the development of such languages should be guided. The purpose of this article is to introduce a set of requirements for such languages and show their application in analyzing and comparing existing modeling languages. DESIGN: The requirements arise from the practical experience of the authors and others in the development of modeling languages in both general informatics and medical informatics. The requirements initially emerged from the analysis of information modeling techniques. The requirements are designed to be orthogonal, i.e., one requirement can be violated without violation of the others. RESULTS: The proposed requirements for any modeling language are that it be "formal" with regard to syntax and semantics, "conceptual," "expressive," "comprehensible," "suitable," and "executable." The requirements are illustrated using both the medical logic modules of the Arden Syntax as a running example and selected examples from other modeling languages. CONCLUSION: Activity diagrams of the Unified Modeling Language, task structures for work flows, and Petri nets are discussed with regard to the list of requirements, and various tradeoffs are thus made explicit. It is concluded that this set of requirements has the potential to play a vital role in both the evaluation of existing domain-specific languages and the development of new ones.

Computerized charting of case reports.

Follow-up schemas are used in the planning of care delivery for patients who had a larynx tumour resection. Because of the diversity of this population, the idea has arisen that control schemas should be tuned to individual patient histories in order to optimize care delivery. To arrive at refined guidelines, detailed analysis of 300 case reports is planned. In this context a patient case report tool PCRT has been developed to support the analysis of computerized case reports. PCRT is based on an existing patient case report language and can generate case report charts using a newly developed charting method implemented with internet-based technology. This paper presents the charting method and explains the charting algorithm.

Formal description of disease courses.

Patient case analysis is an elementary and crucial process clinicians are confronted with daily. The importance and complexity is reflected in the need to discuss individual patient cases in clinicopathological conferences and the documentation of more than 70,000 patient cases in MEDLINE. This paper introduces DCGL, a technique to model disease course descriptions as present in medical literature. DCGL enables advanced computerised matching of generic disease course descriptions with individual patient case descriptions, a basic function in computerised patient case analysis.

Formal description of temporal knowledge in case reports.

Patient case analysis is an elementary and crucial process which clinicians are daily confronted with. The importance and complexity is reflected in the need to discuss cases in clinicopathological conferences and the documentation of more than 70,000 patient cases in MEDLINE. This paper introduces a generic patient case report language (PCRL) based on general medical temporal concepts to formalise temporal knowledge as present in case descriptions. The lack of such a generic technique is reflected by the fact that computers are very restrictive in accepting patient specific temporal information. Acceptance is almost always controlled and guided by specific predefined disease or treatment models. We strive for a case library consisting of unambiguous patient case descriptions formulated independent from future use.

Changing patterns of gene expression in the pulmonary trunk-banded rat heart.

A pressure-overload model in the rat by banding the pulmonary trunk (PT) was developed to investigate alterations in gene expression in left- and right-ventricular compartments during the transition from compensated right-ventricular (RV) hypertrophy to right heart failure. Right heart failure in rat is characterized by liver cirrhosis, hydrothorax and ascites. The diameter of constriction was found to determine the time course of heart failure development. Only the RV free wall and the right atrium increased in weight, without a difference between compensated and failing RV. An increase in circulating ANP revealed a hypertrophic response of the myocardium, while increased circulating ammonia levels discriminated between compensated hypertrophy and failure. As parameters for stress, fibrosis and Ca2+-handling, changes in the pattern and level of the mRNAs encoding atrial natriuretic peptide (ANP), collagenIIIalpha1, and sarcoplasmic endoplasmic reticular calcium ATPase 2 (SERCA2), phospholamban (PLB) and calsequestrin (CSQ) were studied by Northern blot and in situ hybridization analyses. Pulmonary trunk banding resulted in an induction of ANP mRNA, a moderate increase in collagenIII alpha1 mRNA and a decrease in SERCA2 and PLB mRNA levels in both the left and right ventricles, but changes were most pronounced in the myocardium surrounding the RV cavity. Increased ammonia blood levels are a promising prognostic marker to detect the development of right heart failure.

Cardiac ATP breakdown and mechanical function during recurrent periods of anoxia.

The effect of repeated short anoxic or ischemic periods on ATP breakdown and cardiac function remains controversial. To analyze this issue further and to study the regulation of adenine nucleotide breakdown during recurrent cardiac anoxia, we compared two different protocols of intermittent anoxia. Four rat hearts, perfused according to Langendorff, were exposed to 12 periods of anoxia, each lasting 1 minute, with reoxygenation periods of 3 minutes (protocol A). A second group of 8 hearts were made anoxic for 6 periods of anoxia, each lasting 1 minute, followed by 6 periods of anoxia, each lasting 2 minutes, with the same reoxygenation periods (protocol B). Adenosine production was studied with high performance liquid chromatography, ventricular contraction was monitored using a force transducer. During anoxia a substantial vasodilation and immediate fall in strength of ventricular contraction occurred. They were most pronounced during the first anoxic period and during the change from 1 to 2 minute periods of anoxia. Adenosine production was about 1 nmol/min during the first 1-minute anoxic period, decreasing during the following 1-minute anoxic periods. During the first 2-minute anoxic period, a new and much higher adenosine peak was observed (6 nmol/min), decreasing during the following 2-minute anoxic periods. Total purine release followed a pattern similar to that of adenosine. The concentration of ATP at the end of protocol B was 18.5 mumol/g dry tissue, which is significantly lower than that in protocol A (21.6 mumol/g). The results show that ATP breakdown during intermittent anoxia gradually decreases, notwithstanding the presence of substantial amounts of ATP.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthesis of two phosphate-containing "heptasaccharide" fragments of the capsular polysaccharides of Streptococcus pneumoniae types 6A and 6B.

The "heptasaccharides" O-alpha-D-galactopyranosyl-(1----3)- O-alpha-D-glucopyranosyl-(1----3)-alpha, beta-L-rhamnopyranose 2''-[O-alpha-D-galactopyranosyl-(1----3)-O-alpha-D-glucopyranosyl- (1----3)-O-alpha-L-rhamnopyranosyl-(1----3)-D-ribit-5-yl sodium phosphate] (25) and O-alpha-D-galactopyranosyl- (1----3)-O-alpha-D-glucopyranosyl-(1----3)-alpha, beta-L-rhamnopyranose 2''-[O-alpha-D-galactopyranosyl-(1----3)-O-alpha-D-glucopyranosyl- (1----3)-O-alpha-L-rhamnopyranosyl-(1----4)-D-ribit-5-yl sodium phosphate] (27), which are structural elements of the capsular polysaccharides of Streptococcus pneumoniae types 6A and 6B ([----2)- -alpha-D-Galp-(1----3)-alpha-D-Glcp-(1----3)-alpha-L-Rhap- (1----X)-D-RibOH-(5-P----]n; 6A X = 3, 6B X = 4), respectively, have been synthesized. 2,4-Di-O-acetyl- 3-O-[2,4,6-tri-O-acetyl-3-O-(2,3,4,6-tetra-O-acetyl-alpha-D- galactopyranosyl)-alpha-D-glucopyranosyl]-alpha-L-rhamnopyranosyl trichloroacetimidate (13) was coupled with 5-O-allyloxycarbonyl-1,2,4-tri-O- benzyl-D-ribitol (10), using trimethylsilyl triflate as a promotor (----14), and deallyloxycarbonylation (----15) and conversion into the corresponding triethylammonium phosphonate then gave 16. Condensation of 16 with 4-methoxybenzyl 2,4-di-O-benzyl-3-O-[2,4,6-tri-O-benzyl-3-O-(3,4,6-tri-O-benzyl-alpha-D- galactopyranosyl)-alpha-D-glucopyranosyl]- alpha-L-rhamnopyranoside (22) followed by oxidation and deprotection afforded 25. 5-O-Allyl-1-O-allyloxycarbonyl-2,3-di-O-benzyl-D-ribitol (12) was coupled with 13, using trimethylsilyl triflate as a promoter, the resulting tetrasaccharide-alditol derivative 17 was deallyloxycarbonylated (----18), acetylated (----19), and deallylated (----20), and the product was converted into the triethylammonium phosphonate derivative 21. Condensation of 21 with 22 followed by oxidation and deprotection afforded 27.

Image processing algorithms for the analysis of phase-shifted speckle interference patterns.

A sequence of image processing algorithms for the analysis of interference patterns generated by a phaseshifting speckle interferometer is discussed. The goal is the accurate determination of displacement and strain components at the surface of an object. The phase change related to the displacement is accurately calculated from eight digitized interference patterns using a phase-shifting algorithm. Digital image processing algorithms have been developed for phase unwrapping, phase restoration, and phase fitting. During the processing steps a binary mask is used to solve the problem of invalid areas. Experimental results for the strain components at the surface of a simple object demonstrate a repeatability of 0.3-microstrain rms.

Synthesis of structural elements of the capsular polysaccharides of Streptococcus pneumoniae types 6A and 6B.

O-alpha-d-Glucopyranosyl-(1----3)-alpha, beta-L-rhamnopyranose (15), O-alpha-D-galactopyranosyl-(1----3)-O-alpha-D-glucopyranosyl-(1----3)-al pha, beta-L-rhamnopyranose (17), O-alpha-D-galactopyranosyl-(1----3)-O-alpha-D-glucopyranosyl-(1----3)- O-alpha-L-rhamnopyranosyl-(1----3)-D-ribitol (23), and O-alpha-D-galactopyranosyl-(1----3)-O-alpha-D-glucopyranosyl-(1----3)- O-alpha-L-rhamnopyranosyl-(1----4)-D-ribitol (27), which are structural elements of the capsular polysaccharides of Streptococcus pneumoniae types 6A and 6B ([----2)-alpha-D-Galp-(1----3)-alpha-D-Glcp-(1----3)-alpha-L-Rhap- (1----X)- D-Rib-ol-(5-P----]n; 6A X = 3, 6B X = 4), have been synthesised. Ethyl 3-O-allyl-2,4,6-tri-O-benzyl-1-thio-beta-D-glucopyranoside (3) was coupled with benzyl 2,4-di-O-benzyl-alpha-L-rhamnopyranoside (4), and subsequent deallylation (----14) and debenzylation gave 15. Condensation of 14 with ethyl 2,3,4,6-tetra-O-benzyl-1-thio-beta-D-galactopyranoside (2) followed by debenzylation gave 17. Acetylation of 17 followed by removal of AcO-1, conversion into the imidate, coupling with 1,2,4,5-tetra-O-benzyl-D-ribitol (11), deacetylation, and debenzylation gave 23. Coupling of the imidate with 1-O-allyloxycarbonyl-2,3,5-tri-O-benzyl-D-ribitol (12) followed by deallyloxycarbonylation, deacetylation, and debenzylation yielded 27.

Synthesis of a selectively protected trisaccharide building block of the capsular polysaccharide of Streptococcus pneumoniae types 6A and 6B.

4-Methoxybenzyl 2,4-di-O-benzyl-3-O-[2,4,6-tri-O-benzyl-3-O-(3,4,6-tri-O-benzyl-alpha-D- galactopyranosyl)-alpha-D-glucopyranosyl]-alpha-L-rhamnopyranoside (22), a building block for the alpha-D-Galp-(1----3)-alpha-D-Glcp-(1----3)-alpha-L-Rhap fragment of the capsular polysaccharides of Streptococcus pneumoniae types 6A and 6B [----2)-alpha-D-Galp-(1----3)-alpha-D-Glcp-(1----3)-alpha-L-Rhap-( 1----X)-D- RibOH-(5-P----]n (6A, X = 3; 6B, X = 4) has been synthesised. Ethyl 3-O-allyl-2,4,6-tri-O-benzyl-1-thio-beta-D-glucopyranoside was coupled with 4-methoxybenzyl 2,4-di-O-benzyl-alpha-L-rhamnopyranoside in ether, using methyl triflate as promoter. The resulting alpha-D-Glcp-(1----3)-alpha-L-Rhap derivative was deallylated with KOBut in N,N-dimethylformamide followed by 0.1M HCl in 9:1 acetone-water. The product was coupled with 3,4,6-tri-O-acetyl-2-O-allyl-alpha,beta-D-galactopyranosyl trichloroacetimidate in ether, using trimethylsilyl triflate, to yield 19. Deacetylation, benzylation, and deallylation then gave 22.

G.L.C.-M.S. of N-(1-deoxyalditol-1-yl)octadecylamine derivatives in the analysis of methanolysates of neoglycolipids obtained by reductive amination.

Hydrophobic conjugates of a series of aldoses have been prepared by reductive amination with octadecylamine and sodium cyanoborohydride, as model compounds for the analysis of reductively aminated oligosaccharides derived from capsular polysaccharides of Streptococcus pneumoniae. In the context of the methanolysis procedure for sugar analysis, g.l.c. and g.l.c.-m.s. (e.i.-mode) studies were carried out on the N-(1-deoxyalditol-1-yl)octadecylamine derivatives obtained after treatment with methanolic HCl, and subsequent N-acetylation and trimethylsilylation.

Sulfated N-linked carbohydrate chains in porcine thyroglobulin.

N-linked carbohydrate chains of porcine thyroglobulin were released by the hydrazinolysis procedure. The resulting mixture of oligosaccharide-alditols was fractionated by high-voltage paper electrophoresis, the acidic fractions were further separated by high-performance liquid chromatography on Lichrosorb-NH2, and analyzed by 500-MHz 1H-NMR spectroscopy and, partially, by permethylation analysis. Of the acidic oligosaccharide-alditols, the following sulfated carbohydrate chains could be identified: NeuAc alpha 2----6Gal beta 1----4GlcNAc beta 1----2Man alpha 1----3[(SO3Na----3)Gal beta 1----4GlcNAc beta1----2-Mana alpha 1----6]Man beta 1----4GlcNAc beta 1----4[Fuc alpha 1----6]GlcNAc-ol and NeuAc alpha 2----6Gal beta 1----4(SO3Na----)0-1 GlcNAc beta 1----2-Man alpha 1----3[NeuAc alpha 2----6Gal beta 1----4(SO3Na----6)1-0GlcNAc beta 1----2Man alpha 1----6]Man beta 1----4GlcNAc beta 1----4[Fuc alpha 1----6]GlcNAc- ol. The sulfated structural elements for porcine thyroglobulin form novel details of N-linked carbohydrate chains. They contribute to the fine structure of these oligosaccharides and are another type of expression of microheterogeneity.