Medical audit data: counting is not enough.

OBJECTIVE--To assess the meaningfulness of a year''s worth of audit data relating to all the inpatients of one consultant general surgeon and to question the usefulness of certain outcome measures. DESIGN--Analysis of records entered on to audit computer (Dunnfile) and relating to inpatient episodes for one consultant general surgeon over one year. Data obtained were compared with ward records and the patient administration system to check their accuracy. SETTING--The three hospitals and 12 wards in Brighton health district where the surgeon admitted patients. SUBJECTS--859 Records relating to inpatient episodes from 1 January to 31 December 1988. These covered 655 main procedures and 79 secondary procedures performed at the same time. MAIN OUTCOME MEASURES--Procedures were analysed by complexity of operation (BUPA code) and grade of surgeon; complications were counted and rates constructed by surgeon and by BUPA code: returns to theatre were analysed. RESULTS--Simple counts revealed some data, such as the fact that one registrar performed more major operations (32) than the senior registrars (22 and 14), and an analysis of complications showed that he had a lower complication rate (11.4% v 20.0% and 19.4%). But the simple complication rate disclosed nothing about whether the complication was avoidable. Likewise, the number of returns to theatre needed further qualification. Analysis of data collection for February to April 1988 showed a 30% deficit of information on the audit system compared with ward records and prompted a re-examination of everyone''s role in collecting data. After the year''s audit there was still a 17% shortfall compared with the district''s patient administration system, though some of this was accounted for by a backlog of work. CONCLUSIONS--It is difficult to ensure adequate data collection and entails everyone in an unfamiliar discipline. Connecting the audit system to the patient administration system would help. Despite the limitations of crude analyses of workload and complications rates, the audit data helped to measure activity and in the management of the firm. Nevertheless, time and care have to be taken in presenting and interpreting audit data carefully. IMPLICATIONS--Counting is not enough.     

无居民海岛开发生态损害评估——以象山县大羊屿岛为例

无居民海岛独特的生态系统和地理位置决定了受损后的修复成本极高、开发难度极大,其保护与开发已经成为国内外学界关注的重点。基于海岛生态系统服务价值理论构建了无居民海岛开发的生态损害评估模型,以我国首个公开拍卖使用权的大羊屿岛为例验证模型的科学性和可行性,并与2018年调整后的无居民海岛使用金征收标准中生态损害成本额度进行对比分析。研究结果表明：（1）大羊屿岛开发的生态损害补偿金为1644.82万元。其中,陆域开发行为所需的生态损害补偿金为890.19万元,高于海洋开发行为所造成的生态损害补偿金;（2）通过本文计算的海岛陆域生态损害补偿金高出现行海岛使用金标准中的生态损害成本371.90万元,2018年旅游用岛使用金征收标准仍有上调空间。对无居民海岛开发的生态损害评估可以增强政府和企业对于海岛资源的保护意识,重新权衡无居民海岛开发的利弊,避免对海岛资源过度和盲目的开发。     

The theory of multistage integration in the visual brain.

The theory of multistage integration is based on evidence that the visual brain consists of several parallel multistage processing systems, each specialized for a given attribute such as colour or motion. Each stage of a given system processes information at a distinct level of complexity. Our theory supposes that activity at any stage of a given multistage processing system is perceptually explicit--that is to say, it requires no further processing to generate a conscious experience. This activity can be integrated, or bound, with the perceptually explicit activity at any given stage of another or the same multistage processing system. Such binding is therefore not a process that generates a conscious experience, but rather one that brings different conscious experiences together. Many perceptual advantages result from such a flexible and dynamic integrative system. Conversely, there would be disadvantages to limiting perception and binding to hypothetical ''terminal'' stages of such processing systems or to hypothetical ''integrator'' areas. Although we formulate our hypothesis in terms of the visual brain, we believe it might form a general principle of brain functioning.     

Improving benzodiazepine prescribing in family practice through review and education.

Indications for and dosages of four commonly prescribed benzodiazepines were recorded at a family medicine centre with the aid of a computerized data collection system. Four guidelines were then developed for appropriate prescribing of these drugs: (a) benzodiazepines should be used less frequently with increasing age; (b) short-acting drugs are preferable to long-acting drugs; (c) patients 65 years of age and over should receive half the daily dose prescribed for younger patients; and (d) use of these drugs for more than 1 month should be discouraged. After a year''s observation it was evident that none of the guidelines were being followed. The 30 physicians in the practice were then informed of the findings by an educational program. Another 6 months of observation showed a reduction in the prescribing of benzodiazepines to patients 65 years of age and over, a significant shift to the use of short-acting benzodiazepines, and some reduction in the daily dose and duration of administration of diazepam. Thus, such a review of drug prescribing in family practice can be a practical and effective method of improving prescribing patterns.     

A high-pressure sample cell for circular dichroism studies.

The construction and operation of a preparative polyacrylamide-gel electrophoresis system is described. Emerging protein bands are collected by an intermittent pumping system which is based on the design of Brownstone ((1969) Anal. Biochem.27, 25–46). The original pressure-sensitive operation was, however, simplified to time-volume operation. Cooling of the gel by a central cooling finger, essentially according to Jovin et al. ((1964) Anal. Biochem.9, 351–369), has also been added. To accomodate the polyethylene tubing needed for intermittent collection of protein and also the central cooling finger, it is necessary to polymerize the gel in a mold before it is installed in the gel housing compartment of the electrophoresis cell. Gel concentrations of 5% and higher can be used in this system. Dilution of emerging protein samples by the intermittent collection system is kept to a minimum. This fact, together with simplicity of design makes it suitable for general preparative work with polyacrylamide-gel electrophoresis. Operation of the apparatus and resolution of protein bands are demonstrated by separation of bovine serum albumin polymers and thyroxine-binding proteins in human serum.     

Microorganisms of the Upper Atmosphere: I. Instrumentation for Isokinetic Air Sampling at Altitude

An aircraft-mounted air-sampling system for the collection of microorganisms from the upper air is described. The system is highly suitable for use in upper air sampling from an aircraft because (i) it is an isokinetic system, (ii) it is simple to operate, (iii) it employs a dry filter, (iv) the volume sampled can be easily determined, and (v) it operates efficiently at all altitudes and ambient temperatures.     

Understanding physicians' response to AIDS.

Attempts to comprehend physicians'' extreme reaction to AIDS (acquired immune deficiency syndrome) have met with great difficulty since the disease brings into question traditional norms and assumptions. As the medical profession struggles to develop guidelines and policies to help it deal with this disease, it can draw on very little systematic research on the effect of AIDS on physicians'' attitudes and practices. We suggest a framework developed from the literature on physicians'' and society''s response to other disorders that would provide a basis for organizing the ever-increasing amount of information on physicians and AIDS and would guide systematic research aimed at understanding and predicting physicians'' participation in the prevention and management of AIDS. Within this framework we consider how characteristics of the disease, elements of the health care system and physicians'' attitudes interact to influence clinical and personal practices. AIDS had led to new delineations of physicians'' responsibility, modification of prevailing beliefs about physician autonomy and thus a redefinition of the role of the physician in North America.     

Vision without knowledge.

A brain-damaged patient (D.F.) with visual form agnosia is described and discussed. D.F. has a profound inability to recognize objects, places and people, in large part because of her inability to make perceptual discriminations of size, shape or orientation, despite having good visual acuity. Yet she is able to perform skilled actions that depend on that very same size, shape and orientation information that is missing from her perceptual awareness. It is suggested that her intact vision can best be understood within the framework of a dual processing model, according to which there are two cortical processing streams operating on different coding principles, for perception and for action, respectively. These may be expected to have different degrees of dependence on top-down information. One possibility is that D.F.''s lack of explicit awareness of the visual cues that guide her behaviour may result from her having to rely on a processing system which is not knowledge-based in a broad sense. Conversely, it may be that the perceptual system can provide conscious awareness of its products in normal individuals by virtue of the fact that it does interact with a stored base of visual knowledge.     

Monoclonal antibodies to plant growth regulators. II. Indole-3-acetic acid

The production and characterization of high-affinity monoclonal antibodies suitable for the radio- and enzymeimmunoassay of the endogenous plant growth regulator, indole-3-acetic acid (IAA), is reported. Hybridomas were produced by fusion of NS 1 myeloma cells with spleen cells from Balb/c mice immunized with IAA-bovine serum albumin conjugates. From an initial collection of 158 wells containing cells secreting monoclonal antibodies against IAA, seven were used to derive cell clones. Three of these are described here. They secrete immunoglobulin (IgG2a or IgG2b) of high affinity and specificity for IAA methyl ester and can be used to quantite picogram amounts of this compound in plant extracts by radio- and enzymeimmunoassay.     

Biases in three-dimensional structure-from-motion arise from noise in the early visual system.

The projected pattern of retinal-image motion supplies the human visual system with valuable information about properties of the three-dimensional environment. How well three-dimensional properties can be recovered depends both on the accuracy with which the early motion system estimates retinal motion, and on the way later processes interpret this retinal motion. Here we combine both early and late stages of the computational process to account for the hitherto puzzling phenomenon of systematic biases in three-dimensional shape perception. We present data showing how the perceived depth of a hinged plane (''an open book'') can be systematically biased by the extent over which it rotates. We then present a Bayesian model that combines early measurement noise with geometric reconstruction of the three-dimensional scene. Although this model has no in-built bias towards particular three-dimensional shapes, it accounts for the data well. Our analysis suggests that the biases stem largely from the geometric constraints imposed on what three-dimensional scenes are compatible with the (noisy) early motion measurements. Given these findings, we suggest that the visual system may act as an optimal estimator of three-dimensional structure-from-motion.     

Cost of allogeneic and autologous blood transfusion in Canada. Canadian Cost of Transfusion Study Group.

OBJECTIVE: To determine the cost, from a societal perspective, of blood transfusion in Canada. STUDY DESIGN: Cost-structure analysis. SETTING: Data were collected from eight hospitals and from six blood centres operated by the Canadian Red Cross Society in four provinces. OUTCOME MEASURES: Costs associated with four stages of transfusion-- collection, production, distribution and delivery--in 1933 were assessed. Costs were divided into the following categories; personnel, purchases, external services, overhead, donors'' time, patients'' time (for autologous transfusion), wastage and infection. RESULTS: The mean overall cost of a transfusion performed on an inpatient basis was $210 per unit of red blood cells for an allogeneic transfusion and $338 per unit of blood for an autologous transfusion. The mean cost of an allogeneic transfusion performed on an outpatient basis was $280 per unit of red blood cells. CONCLUSION: The costs determined in this study can be used in future studies comparing the cost-effectiveness of allogeneic transfusion with that of alternative methods.     

A system worth saving.

The country will mark Canada Health Day on May 12, so CMAJ asked Dr. Michael Gordon to reflect on Canada''s health care system and the changes it has seen and will see. The special day, cosponsored by the Canadian Public Health Association, is designed to highlight "the need for better communication between health professionals and the communities they serve." In this article, Gordon reflects on the dangers facing Canada''s medicare system and the need to protect it from the inroads threatened by privatization.     

深圳城市生态大数据智慧管理和服务平台技术集成与应用研究

生态环境是人类赖以生存和发展的基础,城市生态大数据智慧管理和服务平台建设是生态城市和美丽城市建设的需要。以深圳市为例,借助物联网、移动互联网、计算机、数据库和网络地理信息系统技术,以及时空地理大数据整合和共享、大数据挖掘分析和云端一体化业务协同等关键技术,结合城市生态系统评估分析决策模型/方法/对策库,在实现深圳市“空-地-网-统计-众源”等多源异构生态大数据有效集成的基础上,搭建了 “数据采集-信息提取-知识发现-决策生成-快速服务”全流程、一体化的深圳市生态大数据智慧管理和服务平台,构建了面向业务部门和科研人员等专业用户的生态野外数据调查采集系统和城市生态监测与评估管理决策分析系统,以及面向社会大众的深圳生态大调查APP。平台首次揭示了深圳市1979年以来不同生态系统的格局、构成、过程、服务和健康状况的变化,提升了深圳市生态环境综合决策科学化、生态环境监管精准化、生态环境公共服务便民化水平。平台有效降低了用户数据收集与处理和操作专业模型的难度,突破了原始数据应用的瓶颈和难点,提高了专业模型在业务部门中的使用率。未来,依靠“生态大数据+生态专业模型”的技术方案实现从数据到知识的挖掘,是实现城市生态大数据智慧化和专业化管理的关键,也是全面提高城市生态环境保护信息化服务水平的重要途径。     

Scaling-Laws of Human Broadcast Communication Enable Distinction between Human,Corporate and Robot Twitter Users

Human behaviour is highly individual by nature, yet statistical structures are emerging which seem to govern the actions of human beings collectively. Here we search for universal statistical laws dictating the timing of human actions in communication decisions. We focus on the distribution of the time interval between messages in human broadcast communication, as documented in Twitter, and study a collection of over 160,000 tweets for three user categories: personal (controlled by one person), managed (typically PR agency controlled) and bot-controlled (automated system). To test our hypothesis, we investigate whether it is possible to differentiate between user types based on tweet timing behaviour, independently of the content in messages. For this purpose, we developed a system to process a large amount of tweets for reality mining and implemented two simple probabilistic inference algorithms: 1. a naive Bayes classifier, which distinguishes between two and three account categories with classification performance of 84.6% and 75.8%, respectively and 2. a prediction algorithm to estimate the time of a user''s next tweet with an . Our results show that we can reliably distinguish between the three user categories as well as predict the distribution of a user''s inter-message time with reasonable accuracy. More importantly, we identify a characteristic power-law decrease in the tail of inter-message time distribution by human users which is different from that obtained for managed and automated accounts. This result is evidence of a universal law that permeates the timing of human decisions in broadcast communication and extends the findings of several previous studies of peer-to-peer communication.     

Graves' ophthalmopathy.

Graves'' ophthalmopathy usually occurs in association with hyperthyroidism. Its occasional occurrence in the absence of thyroid disease suggests, however, that it may be a separate autoimmune disorder. While the evidence supporting an autoimmune pathogenesis is considerable for the ophthalmopathy, it is not so impressive as that for Graves'' hyperthyroidism: orbital antibodies have not been convincingly demonstrated and autoantigens have not been identified. On the other hand, in patients with Graves'' ophthalmopathy the orbital tissues and eye muscle membranes are infiltrated with lymphoid cells and show evidence of cell-mediated immune reactions. Although there is some evidence that binding of thyroid stimulating hormone fragments and thyroglobulin-antithyroglobulin immune complexes to eye muscle membranes may be important in the pathogenesis of the ophthalmopathy, this needs to be confirmed. The mechanism for the association of hyperthyroidism and ophthalmopathy is unknown, but the association likely reflects an influence of thyroid hormones on the immune system. In view of the autoimmune pathogenesis the logical treatment of Graves'' ophthalmopathy appears to be immunosuppression.     

Making better decisions: construction of clinical scoring systems by the Spiegelhalter-Knill-Jones approach.

A study was carried out assessing the practical use of a simple system of scoring information which can help in making a diagnosis or establishing a prognosis in an individual patient. The system was introduced in 1984 for use in gastroenterology, but it can be employed in a wide range of medical and surgical settings. This series was concerned with predicting postoperative respiratory complications in a group of elderly surgical patients. The system combines elements from Baye''s theorem and logistic regression, though no mathematical knowledge is required to apply it in clinical practice. The method by which results are presented is easy to understand, yet at the same time more complex ideas such as conflict of evidence and doubt may be embraced if the clinician so desires.     

Dr. Balfour Mount and the cruel irony of our care for the dying.

Dr. Balfour Mount of Montreal thinks that the health care system, because of its fixation on disease processes, may have forgotten that it also has a mandate to alleviate suffering. "We need to recapture that vision," says Mount, who describes palliative medicine as a "rich combination" of clinical pharmacology, rehabilitation medicine and internal medicine. Mount says there is a cruel irony in our care of the dying. "Although these are the sickest people in our health care system, when medical technology doesn''t know what to do, the quality and quantity of care falls away. How can we justify that?"     

Artificial intelligence for carbon emissions using system of systems theory

The impact of artificial intelligence (AI) on the environment is the subject of discourse, with arguments for both positive and negative effects. There is a fine line between AI for good and AI for environmental degradation. Today, companies want to seize the benefits of AI, which distinctively involves reducing the company's carbon footprint. However, AI's carbon emissions differ as per the techniques involved in training it. As the saying goes, a coin always has two sides. Therefore, it cannot be denied that AI can be an effective tool for combating climate change, but its role in contributing to carbon emissions cannot be ignored. Multiple studies indicate that AI could be the game-changer in staving off anthropogenic climatic changes due to the deterioration of the environment and global warming. This double-edged relationship and interdependency of AI and carbon emissions are represented through a system of systems (SoS) approach. SoS states that a plan is created through multiple smaller systems, creating complexity in the design and vice versa. A complex system can be assumed as the world in general, where two individual independent systems AI and carbon emissions, when in interaction, create a complex complementary and contradictory relation, adding to the convolution of the system. This connection is demonstrated by conducting a network analysis and calculating the carbon emissions of six machine learning (ML) algorithms and deep learning (DL) models with different datasets but the same hyperparameters on a carbon emission calculator created through AI algorithms. The primary idea of this study is to encourage the AI society to create efficient AI models that may be used without compromising environmental issues. The focus should be on practicing sustainable AI, that is, sustainability from data collection to model deployment, throughout the lifecycle of AI.     

A system for monitoring and improving animal visibility and its implications for zoological parks

With the growing trend in zoos to build complex, naturalistic exhibits comes the potential for exhibits to be so densely vegetated or complex that animals are not easily seen by zoo visitors. This can negatively impact the visitor's visiting experience and the zoo's ability to communicate conservation and education messages. Over the past 9 years, Disney's Animal Kingdom^® has developed a process for monitoring and improving the visibility of animals on display to the public. This animal visibility process utilizes a data collection system whereby systematic observations are collected each week. The percentage of observations where at least one animal was visible is recorded for each species and compared to an 80% visibility criterion. Species that do not reach this criterion for 4 consecutive weeks are discussed at animal management meetings. If the problems associated with animal visibility cannot be easily solved, the animal‐care teams partner with the research team to conduct a second process, called the Visibility Issues Process. This process provides additional information for the animal‐care team to utilize in developing a plan to improve visibility. Although the processes described here are specific to the infrastructure at Disney's Animal Kingdom^®, the basic concepts of (1) a formalized visibility data collection process, (2) a visibility criterion to which managers of species are held accountable, and (3) a process for planning to improve animal visibility without negatively impacting animal welfare are fundamental concepts that can be developed at individual institutions and incorporated into that zoo's existing infrastructure. Zoo Biol 29:68–79, 2010. © 2009 Wiley‐Liss, Inc.