A comparison of Geriatric Depression Scale scores in older Australian and Japanese women.

AIMS: The aim of this study was to compare the prevalence of depressive symptoms in Australian and Japanese populations of community-dwelling older women using the Geriatric Depression Scale (GDS-15). In addition, the relationship between lifestyle and health factors and higher ratings of depressive symptoms was also examined to determine if there were culturally consistent risk factors associated with higher depressive symptom scores. METHODS: A total of 444 community based women aged between 65 and 77 years completed a depressive symptom measure (GDS-15) and provided information on common lifestyle factors. The Australian sample (n = 222) were drawn from the Women's Healthy Ageing Project and the age-matched, Japanese sample from the Kumamoto Ageing Study of Mental Health (n = 222). The GDS was chosen to; (1) reduce the impact of physical symptoms associated with old age and, (2) reduce the inflation in scores that may result from the Japanese tendency to endorse somatic items more often than Western adults. RESULTS: Mean GDS total scores were significantly higher for the Japanese population 3.97 ± 3.69 compared with 1.73 ± 2.7 for Australian women. The percentages of women scoring in the normal; mild and moderate ranges for depression were 91, 7 and 2% for Australia and 67, 24 and 9% for Japan. Scores remained significantly higher for the Japanese cohort when controlling for lifestyle and health factors associated with depression. The analysis of lifestyle and health characteristics showed that the greatest difference between cohorts was in the area of living status, with more Australian women living with their partner and more than three times as many Japanese women living with their children. When the data for the countries was considered independently employment status affected the likelihood of higher depression scores in the Australian sample while heart disease and poor sleep impacted the risk for the Japanese population. CONCLUSIONS: Significantly more Japanese women scored within the mild and moderate ranges on the GDS compared with their Australian peers, even when controlling for possible confounding factors. Of the lifestyle and health factors assessed in this analysis no single variable was a common risk factor for higher depressive scores for both countries. The presence of cultural influences that may impact the risk of experiencing depressive symptoms, and culture specific patterns of item endorsement on depressive symptom measures, needs to be explored in more detail.

Challenges in the development and testing of a reference terminology model for nursing interventions.

The purpose of this paper is to report the work of the Interventions Group of the first Nursing Terminology Summit (1999) and to describe the challenges and insights of this group as they have evolved a reference terminology model for nursing interventions. When the group began its work as part of the first meeting of the Nursing Terminology Summit, it had the overall objective of proposing the intervention component of a reference terminology model for nursing. Although there is not a definitive proposal for this to date, the group's exploration and analysis has clarified and explicated both the types of models of clinical information and the current " state of the art" of formal representations of nursing interventions as well as the relationship of nursing languages to these formal representations. In addition, it is our perspective that the work of this group is representative of the process and challenges facing many similar groups currently engaged in modeling efforts. Consequently, critical success factors of such efforts are identified and discussed. This paper reports both the specific outputs of the group related to progress in defining a terminology model of nursing interventions and observations and lessons learned regarding consensus modeling work.

Chronic wound caring ... a long journey toward healing.

Healthcare professionals use words like "frustrating," "expensive," and "time-consuming" to describe chronic wound care. Healing a wound that has been present for an extended period of time is difficult. Often the problem is not just the wound but also the "woundedness" of the individual with the wound. The patient's needs in chronic wound care often continue over months, years, or even a lifetime. This article addresses more than the wound--it offers healthcare professionals' accounts of patient stories and their active involvement in the long journey toward chronic wound healing.

An evaluation of ICNP intervention axes as terminology model components.

In this paper we evaluate selected axes of the International Classification of Nursing Practice (ICNP) as terminology model components for nursing actions by dissecting and categorizing two data sets of term phrases (Patient Care Data Set and Home Health Care Classification). Second, we critically analyze the relationships between the ICNP axes and terminology model components used to formally define procedures (including nursing actions) in SNOMED RT. Our findings demonstrate that the semantic categories represented by the ICNP intervention axes are relevant sources for terminology model components for nursing actions. In addition, our findings suggest that only minimal additions or extensions to the current semantic links of SNOMED RT are needed to support the formal definition of nursing actions such as those contained in PCDS and HHCC.

Toward vocabulary domain specifications for health level 7-coded data elements.

The "vocabulary problem" has long plagued the developers, implementers, and users of computer-based systems. The authors review selected activities of the Health Level 7 (HL7) Vocabulary Technical Committee that are related to vocabulary domain specification for HL7 coded data elements. These activities include: 1) the development of two sets of principles to provide guidance to terminology stakeholders, including organizations seeking to deploy HL7-compliant systems, terminology developers, and terminology integrators; 2) the completion of a survey of terminology developers; 3) the development of a process for HL7 registration of terminologies; and 4) the maintenance of vocabulary domain specification tables. As background, vocabulary domain specification is defined and the relationship between the HL7 Reference Information Model and vocabulary domain specification is described. The activities of the Vocabulary Technical Committee complement the efforts of terminology developers and other stakeholders. These activities are aimed at realizing semantic interoperability in the context of the HL7 Message Development Framework, so that information exchange and use among disparate systems can occur for the delivery and management of direct clinical care as well as for purposes such as clinical research, outcome research, and population health management.

Photographic assessment of the appearance of chronic pressure and leg ulcers.

The purpose of this paper was to examine the validity and reliability of using photographs of wounds to accurately assess wound status. The results of assessing wound appearance using wound photographs was compared to results obtained from a bedside assessment using the Pressure Sore Status Tool (PSST). The photographic wound assessment tool (PWAT) used in this comparison represents a modified version of the PSST and includes the six domains that can be determined from wound photographs. The PWAT was used on photographs of both chronic pressure ulcers (n = 56) and leg ulcers due to vascular insufficiency (n = 81). The photographic tool has excellent intrarater (ICC = 0.96) and interrater (ICC = 0.73) reliability and good concurrent validity (r = 0.70) compared with a full bedside assessment PSST. The PWAT has also shown to be sensitive to change in wound appearance of healing ulcers, but not nonhealing ulcers. These results would suggest that in the event that a full bedside assessment is not possible, wound photographs may be used to accurately assess wound appearance of both chronic pressure ulcers located on the trunk and vascular ulcers of the lower extremity. Establishing a valid and reliable assessment of wound healing using photographic images is of great relevance to the advancing fields of computer image analysis and telemedicine.

Choosing an adjunctive therapy for the treatment of chronic wounds.

Adjunctive therapies such as ultrasound, laser, ultraviolet light, superficial heating, pulsed electromagnetic fields, and electrical stimulation have all been indicated in the treatment of chronic wounds. The purpose of this article is to outline the issues a healthcare professional must consider when choosing the best adjunctive therapy for a chronic wound. It summarizes the effects of therapeutic modalities on the wound healing process, analyzes the clinical research evidence, discusses practical considerations, and reviews indications, contraindications, precautions, and safety considerations. Finally, an algorithm is presented to help guide the clinician in selecting a modality. In summary, research evidence exists in the literature that suggests these adjunctive therapies can directly stimulate new tissue growth, augment wound tissue strength, improve local circulation and oxygenation, reduce edema, and/or inhibit bacterial growth. Electrical stimulation and ultrasound are the only therapeutic modalities that currently have sufficient clinical research evidence to support their use in the treatment of chronic wounds. Practical issues such as cost, time and training required, and patient and therapist safety concerns, will ultimately influence the selection of these modalities.

Pressure ulcer assessment instruments: a critical appraisal.

Numerous evaluation tools have been developed to document various aspects of wound status or appearance of pressure ulcers. These include the Pressure Sore Status Tool (PSST), Pressure Ulcer Scale for Healing (PUSH Tool), Sussman Wound Healing Tool (SWHT), Sessing scale, and the Wound Healing Scale (WHS). A critical appraisal of the literature was undertaken to examine the purpose and methods for the development of each instrument, the extent to which the instruments have been validated to date, the practicality of their use, and the work that remains to be done to establish their suitability for clinical and/or research purposes. All of these instruments have been developed to describe and evaluate change in pressure ulcer status over time with the exception of the WHS, which was developed as an alternative to reverse staging. More of the validation parameters have been addressed for the PSST and the Sessing scale than for the PUSH Tool, the SWHT, and the WHS. All of the instruments can be completed within approximately 5 minutes except the PSST, which requires 10 to 15 minutes to complete. For all instruments, experience with wounds and training in the use of the instrument are required to improve reliability. For each of the measurement instruments, suggestions are made that would complete necessary validation procedures and thus prepare the instruments for clinical and/or research purposes.

In vitro patch-clamp studies in skin fibroblasts.

We have conducted single-channel patch-clamp experiments in skin fibroblasts maintained in culture. Two different cell lines, a mouse 3T3-L1 cell line and a human B17 cell line, were selected for these pilot studies. Recordings were made from both cell-attached and excised inside-out patches at room temperature. In the case of the 3T3-L1 cells, the success rate in obtaining good seals (> 1Gomega) was low, and channel openings in either cell-attached or excised patches were rare. We have, however, identified a channel in a cell-attached configuration with a slope conductance of 39 pS in symmetrical K+ solutions. In the case of the human B17 cells, good quality seals were more readily obtained. One principal type of channel opening was identified. In cell-attached patches, the prevalent type of channel in symmetrical K+ solutions had a conductance of 187 pS. This channel was activated by strong depolarization, and there was usually more than one active channel in the patch. It was blocked by extracellular tetraethylammonium (20 mM), and persisted when external Cl- was replaced by aspartate. In excised inside-out patches bathed in symmetrical K+, this channel was activated by an increase in Ca+ applied to the intracellular face. A large conductance channel (175 pS) was also observed in excised inside-out patches, with a reverse physiological K+ gradient. This channel had a reversal potential > 40 mV and appeared not to be voltage-dependent under these recording conditions (2 mM Ca(2+)i). We conclude that the channel we have identified in these cells belongs to the maxi-K+ channel class.

Scalable methodologies for distributed development of logic-based convergent medical terminology.

As the size and complexity of medical terminologies increase, terminology modelers are increasingly hampered by lack of tools and methods to manage the development process. This paper presents our use and ongoing evaluation of a description-logic classifier to support cognitive scalability of the underlying terminology and our enhancements to that classifier to support concurrent development utilizing semantics-based concurrency control methods. Our enhancements, collectively referred to as the Gálapagos, consist of several applications that take locally-developed terminology enhancements from multiple sites, identify conflicting design decisions, support the modelers' reconciliation of the conflicting designs, and efficiently disseminate updates tailored for locally enhanced terminologies. We have tested our ideas through concurrent evolutionary enhancement of SNOMED International at three Kaiser Permanente regions and the Mayo Clinic. We have found that the underlying environment has met our design objectives, and supports semantic-based concurrency control, and identification and resolution of conflicting design decisions.

Representing thoughts, words, and things in the UMLS.

The authors describe a framework, based on the Ogden-Richards semiotic triangle, for understanding the relationship between the Unified Medical Language System (UMLS) and the source terminologies from which the UMLS derives its content. They pay particular attention to UMLS's Concept Unique Identifier (CUI) and the sense of "meaning" it represents as contrasted with the sense of "meaning" represented by the source terminologies. The CUI takes on emergent meaning through linkage to terms in different terminology systems. In some cases, a CUI's emergent meaning can differ significantly from the original sources' intended meanings of terms linked by that CUI. Identification of these different senses of meaning within the UMLS is consistent with historical themes of semantic interpretation of language. Examination of the UMLS within such a historical framework makes it possible to better understand the strengths and limitations of the UMLS approach for integrating disparate terminologic systems and to provide a model, or theoretic foundation, for evaluating the UMLS as a Possible World--that is, as a mathematical formalism that represents propositions about some perspective or interpretation of the physical world.

Evaluation of a "lexically assign, logically refine" strategy for semi-automated integration of overlapping terminologies.

OBJECTIVE: To evaluate a "lexically assign, logically refine" (LALR) strategy for merging overlapping healthcare terminologies. This strategy combines description logic classification with lexical techniques that propose initial term definitions. The lexically suggested initial definitions are manually refined by domain experts to yield description logic definitions for each term in the overlapping terminologies of interest. Logic-based techniques are then used to merge defined terms. METHODS: A LALR strategy was applied to 7,763 LOINC and 2,050 SNOMED procedure terms using a common set of defining relationships taken from the LOINC data model. Candidate value restrictions were derived by lexically comparing the procedure's name with other terms contained in the reference SNOMED topography, living organism, function, and chemical axes. These candidate restrictions were reviewed by a domain expert, transformed into terminologic definitions for each of the terms, and then algorithmically classified. RESULTS: The authors successfully defined 5,724 (73%) LOINC and 1,151 (56%) SNOMED procedure terms using a LALR strategy. Algorithmic classification of the defined concepts resulted in an organization mirroring that of the reference hierarchies. The classification techniques appropriately placed more detailed LOINC terms underneath the corresponding SNOMED terms, thus forming a complementary relationship between the LOINC and SNOMED terms. DISCUSSION: LALR is a successful strategy for merging overlapping terminologies in a test case where both terminologies can be defined using the same defining relationships, and where value restrictions can be drawn from a single reference hierarchy. Those concepts not having lexically suggested value restrictions frequently indicate gaps in the reference hierarchy.

The Unified Medical Language System: toward a collaborative approach for solving terminologic problems.

The approach taken by the Unified Medical Language System (UMLS), in which disparate terminology systems are integrated, has allowed construction of an electronic thesaurus (the Metathesaurus) that avoids imposing any restrictions upon the content, structure, or semantics of the source terminologies. As such, the UMLS has served as a unifying paradigm by providing appropriate links among equivalent entities that are used in different contexts or for different purposes. It accordingly provides a vehicle through which possibly orthogonal semantic models can co-exist within a single framework. This framework provides a model for the collaborative evolution of biomedical terminology and allows a synergistic relationship between the UMLS and its source terminology systems.

Compositional concept representation using SNOMED: towards further convergence of clinical terminologies.

This paper describes several approaches to the expression and coding of clinical concepts as composites of elementary entities, and describes an approach based on SNOMED RT that may permit further convergence of clinical terminology efforts. We explain the shortcomings of previous approaches to compositional concept representation, as well as the reasons for SNOMED's current approach, which adopts a foundation based in description logics (DLs). The DL model has many advantages: it establishes a formal semantics for SNOMED assertions and suggests a syntax; it provides a basis for understanding expressiveness and computational complexity, through correspondence with known results from DLs; and it helps to clarify the relationships among existing concept representation methods in SNOMED, NHS Clinical Terms (formerly the Read Codes), and GALEN, making a path to convergence more clear.

A "lexically-suggested logical closure" metric for medical terminology maturity.

Medical Terminologies are becoming increasingly expressive secondary to their increase in size, and are becoming increasingly difficult to analyze secondary to inconsistencies in their use and complex interrelationships that are often not explicitly defined. To address these problems, SNOMED-RT is being developed to allow consistent use, and to define explicitly interrelationships between terms. Ensuring the quality of a terminology system like SNOMED-RT presents new challenges which we are trying to address with theoretically-grounded methodologies for quality management. Here we describe an initial metric toward achieving this goal called "lexically-suggested logical closure." We explain how this metric can be useful for tracking the maturity and quality of a terminology, and apply this metric to track the progress of SNOMED-RT development over a portion of its life-cycle.

Reproducibility of interpreting "and" and "or" in terminology systems.

High quality terminologies are a fundamental requirement in a range of health care applications. To ensure high quality terminologies we should reflect about the understandability, reproducibility and utility criteria within a terminology. This paper describes efforts to improve the understandability of SNOMED. We describe the problem related to the grammatical conjunctions "and" and "or" and how we applied basic semantic rules defined by the SNOMED Editorial Board. The results show that the meaning of "and" and "or" in SNOMED can be made explicit in almost all cases and can be done in a reasonable, reliable, and reproducible manner.

Computer-facilitated collaboration: experiences building SNOMED-RT.

Collaborative development involving both individuals and groups is often less efficient than independent development because of communication overhead and integration costs. Despite the decreased development efficiency, collaborations promise more general-purpose products because of the opportunity for integration, with negotiation and reconciliation of diverse perspectives. Collaborations are also perhaps less costly when considered in contexts where there is significant duplication of effort. Computer-facilitated collaboration can reduce the communication and integration burden such that the increased effort required to manage a successful collaboration focuses primarily on the development of shared conceptual model among the developers by requiring that the work product be independently reproducible. This reproducibility requirement incorporates formal quality assurance processes into the development process. In this paper, we describe our initial experiences developing SNOMED-RT using such a computer-facilitated collaborative process. We quantify the extra costs incurred to achieve consistency in our efforts and reproducibility of our results.

SNOMED RT: a reference terminology for health care.

We describe the framework for SNOMED RT (Reference Terminology), designed to complement the broad coverage of medical concepts in SNOMED with a set of enhanced features that significantly increases its value as a reference terminology for representing clinical data. We describe what is meant by a reference terminology, and differentiate SNOMED RT from specialized terminologies that enable user interfaces, electronic messaging, or natural language processing, as well as from other specialized reference terminologies whose primary purpose is for representing data that is not primarily clinical in nature. We then describe how SNOMED RT represents multiple hierarchies and incorporates description logic. We believe that such a comprehensive set of concepts at multiple levels of granularity, with multiple logic-based subsumption hierarchies can meet the requirements of a reference terminology for health care.

The content coverage of clinical classifications. For The Computer-Based Patient Record Institute's Work Group on Codes & Structures.

BACKGROUND AND OBJECTIVE: Patient conditions and events are the core of patient record content. Computer-based records will require standard vocabularies to represent these data consistently, thereby facilitating clinical decision support, research, and efficient care delivery. To address whether existing major coding systems can serve this function, the authors evaluated major clinical classifications for their content coverage. METHODS: Clinical text from four medical centers was sampled from inpatient and outpatient settings. The resultant corpus of 14,247 words was parsed into 3,061 distinct concepts. These concepts were grouped into Diagnoses, Modifiers, Findings, Treatments and Procedures, and Other. Each concept was coded into ICD-9-CM, ICD-10, CPT, SNOMED III, Read V2, UMLS 1.3, and NANDA; a secondary reviewer ensured consistency. While coding, the information was scored: 0 = no match, 1 = fair match, 2 = complete match. RESULTS: ICD-9-CM had an overall mean score of 0.77 out of 2; its highest subscore was 1.61 for Diagnoses. ICD-10 scored 1.60 for Diagnoses, and 0.62 overall. The overall score of ICD-9-CM augmented by CPT was not materially improved at 0.82. The SNOMED International system demonstrated the highest score in every category, including Diagnoses (1.90), and had an overall score of 1.74. CONCLUSION: No classification captured all concepts, although SNOMED did notably the most complete job. The systems in major use in the United States, ICD-9-CM and CPT, fail to capture substantial clinical content. ICD-10 does not perform better than ICD-9-CM. The major clinical classifications in use today incompletely cover the clinical content of patient records; thus analytic conclusions that depend on these systems may be suspect.