Patients' experience with a diabetes support programme based on an interactive electronic medical record: qualitative study

Objective To describe the experiences of patients with type 2 diabetes in a web based disease management programme based on an interactive electronic medical record.Design Qualitative analysis of semistructured interviews with patients enrolled in a diabetes care module that included access to their electronic medical record, secure email, ability to upload blood glucose readings, an education site with endorsed content, and an interactive online diary for entering exercise, diet, and medication.Setting Patients'' homes in Washington state, United States.Participants Nine participants aged 45-65 completed interviews before and after they used the programme.Results Six themes emerged: feeling that non-acute concerns are uniquely valued; enhanced sense of security about health and health care; frustration with unmet expectations; feeling more able to manage; valuing feedback; and difficulty fitting the programme into activities of daily life. Three themes—valuing non-acute concerns, feeling secure, and unmet expectations—have particular relevance to the design and use of web based tools for care of patients with diabetes and chronic medical conditions.Conclusion Participants'' experiences support further study of open access to the electronic medical record and online communication between patients and their care providers. The development of web based disease management programmes should take into account the specific needs and expectations of patients, and patients and providers should have candid discussions about what web based care can and cannot provide.     

Rational choice,neuroeconomy and mixed emotions

Experimental psychology has shown differences between predictions of theory of decision and human choices. Emotions like regret can partly explain these differences. Neuroimagery used in combination with behavioural economics (neuroeconomics) has been used in order to try to disentangle the different emotional and rational factors (regret, rejoicing, reward, costs, uncertainty, trade-off between positive and negative aspects of different options). Emotions then appear as much more complex and mixed affective states than usually assumed. Not only might we feel a positive affect in punishing unfair partners, but mixed emotions can, for example, combine transmutation of previous anxiety into relief and elation by comparison with another less exciting option (elating relief). At the level of complexity of these mixed emotions—which we formally represent by comparisons between ‘unexpected utilities’ and expected ones—the main biases that Kahnemann and Tversky have shown can be explained. In spite of the complexity of these mixed emotions, some of these hypotheses might be partially tested by brain imagery.     

Water Stress Enhances Ethylene-mediated Leaf Abscission in Cotton

Abscission of cotyledonary leaves from cotton (Gossypium hirsutum L. cv. Stoneville 213) seedlings occurred following relief from water stress. The amount of abscission was related to the magnitude of the plant water deficit. Leaf abscission promoted by exogenous ethylene was enhanced in seedlings subjected to water stress. Treatment with ethylene (2.0 to 3.2 microliters of ethylene per liter of air for 24 hours) raised the threshold plant water potential required to induce abscission from —17 to —7 bar, indicating that the stress caused the tissue to become predisposed to ethylene action. Based on the abscission response curve for seedlings treated with ethylene while under water stress, this apparent predisposition was developed as the plant water potentials reached the —7 to —10 bar range. The abscission-promoting effects of ethylene in combination with water stress were reversed with 15% CO₂ at plant water potentials above —12 bar, but the CO₂ reversal was lost at lower water potentials. These results are compatible with the concept that ethylene plays a regulatory role in leaf abscission induced by water stress.     

Neuromuscular training and the risk of leg injuries in female floorball players: cluster randomised controlled study

Objective To investigate whether a neuromuscular training programme is effective in preventing non-contact leg injuries in female floorball players.Design Cluster randomised controlled study.Setting 28 top level female floorball teams in Finland.Participants 457 players (mean age 24 years)—256 (14 teams) in the intervention group and 201 (14 teams) in the control group—followedup for one league season (six months).Intervention A neuromuscular training programme to enhance players’ motor skills and body control, as well as to activate and prepare their neuromuscular system for sports specific manoeuvres.Main outcome measure Acute non-contact injuries of the legs.Results During the season, 72 acute non-contact leg injuries occurred, 20 in the intervention group and 52 in the control group. The injury incidence per 1000 hours playing and practise in the intervention group was 0.65 (95% confidence interval 0.37 to 1.13) and in the control group was 2.08 (1.58 to 2.72). The risk of non-contact leg injury was 66% lower (adjusted incidence rate ratio 0.34, 95% confidence interval 0.20 to 0.57) in the intervention group.Conclusion A neuromuscular training programme was effective in preventing acute non-contact injuries of the legs in female floorball players. Neuromuscular training can be recommended in the weekly training of these athletes.Trial registration Current Controlled Trials ISRCTN26550281.     

Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome

Objective To investigate whether placebo effects can experimentally be separated into the response to three components—assessment and observation, a therapeutic ritual (placebo treatment), and a supportive patient-practitioner relationship—and then progressively combined to produce incremental clinical improvement in patients with irritable bowel syndrome. To assess the relative magnitude of these components.Design A six week single blind three arm randomised controlled trial.Setting Academic medical centre.Participants 262 adults (76% women), mean (SD) age 39 (14), diagnosed by Rome II criteria for and with a score of ≥150 on the symptom severity scale.Interventions For three weeks either waiting list (observation), placebo acupuncture alone (“limited”), or placebo acupuncture with a patient-practitioner relationship augmented by warmth, attention, and confidence (“augmented”). At three weeks, half of the patients were randomly assigned to continue in their originally assigned group for an additional three weeks.Main outcome measures Global improvement scale (range 1-7), adequate relief of symptoms, symptom severity score, and quality of life.Results At three weeks, scores on the global improvement scale were 3.8 (SD 1.0) v 4.3 (SD 1.4) v 5.0 (SD 1.3) for waiting list versus “limited” versus “augmented,” respectively (P<0.001 for trend). The proportion of patients reporting adequate relief showed a similar pattern: 28% on waiting list, 44% in limited group, and 62% in augmented group (P<0.001 for trend). The same trend in response existed in symptom severity score (30 (63) v 42 (67) v 82 (89), P<0.001) and quality of life (3.6 (8.1) v 4.1 (9.4) v 9.3 (14.0), P<0.001). All pairwise comparisons between augmented and limited patient-practitioner relationship were significant: global improvement scale (P<0.001), adequate relief of symptoms (P<0.001), symptom severity score (P=0.007), quality of life (P=0.01).Results were similar at six week follow-up.Conclusion Factors contributing to the placebo effect can be progressively combined in a manner resembling a graded dose escalation of component parts. Non-specific effects can produce statistically and clinically significant outcomes and the patient-practitioner relationship is the most robust component.Trial registration Clinical Trials NCT00065403.     

The Hospital Medical Advisory Committee—The Cabinet of the Medical Staff

Before a hospital medical staff can realistically accept responsibility for the professional practices of its members, a principle initially fostered by the American College of Surgeons and adopted by both the Canadian and American accreditation programs, it must have an effectively functioning medical staff organization. The medical advisory committee is the most important committee of the medical staff organization. A representative composition, adherence to sound administrative principles, and recognition of its prime functions of co-ordination, supervision and jurisdiction will permit this committee—and the total medical staff organization—to discharge adequately the very important responsibilities delegated to them by the governing board of the hospital. Properly structured medical staff bylaws with clearly defined terms of reference assist the smooth functioning of the “cabinet” of the medical staff and safeguard the prerogatives of the individual members of the staff.     

A NEW VASOCONSTRICTOR—A Preliminary Report

Otrivin,® a compound of the hydrochloride salt of phenyl-aminomethylimidazoline, was administered to 74 patients for varying periods as a nasal vasoconstrictor. Seventy-three had relief of nasal congestion for from five to six hours—longer periods than had been obtained with other vasoconstrictors they had used. No pressor effect was noted.     

Pigeons (Columba livia) as Trainable Observers of Pathology and Radiology Breast Cancer Images

Pathologists and radiologists spend years acquiring and refining their medically essential visual skills, so it is of considerable interest to understand how this process actually unfolds and what image features and properties are critical for accurate diagnostic performance. Key insights into human behavioral tasks can often be obtained by using appropriate animal models. We report here that pigeons (Columba livia)—which share many visual system properties with humans—can serve as promising surrogate observers of medical images, a capability not previously documented. The birds proved to have a remarkable ability to distinguish benign from malignant human breast histopathology after training with differential food reinforcement; even more importantly, the pigeons were able to generalize what they had learned when confronted with novel image sets. The birds’ histological accuracy, like that of humans, was modestly affected by the presence or absence of color as well as by degrees of image compression, but these impacts could be ameliorated with further training. Turning to radiology, the birds proved to be similarly capable of detecting cancer-relevant microcalcifications on mammogram images. However, when given a different (and for humans quite difficult) task—namely, classification of suspicious mammographic densities (masses)—the pigeons proved to be capable only of image memorization and were unable to successfully generalize when shown novel examples. The birds’ successes and difficulties suggest that pigeons are well-suited to help us better understand human medical image perception, and may also prove useful in performance assessment and development of medical imaging hardware, image processing, and image analysis tools.     

The Need for Continuing Medical Education

Continuing medical education is an essential feature of the practice of modern medicine since it furnishes the means to maintain the doctor''s ability to provide quality patient care.To ensure that continuing medical education is provided efficiently and in the best quality, and utilized fully, it is necessary that: (1) the medical faculty inculcate in the student the concept of lifelong learning; (2) the practitioner adopt less time-consuming patterns of practice, to free more of his time for learning; (3) community hospital-based clinical teaching be provided universally; and (4) research be conducted to determine the best of current teaching methods and develop better ones. Conflicting efforts to meet these needs by practitioners (whose primary responsibility it is) and by organized medicine, specialty societies, voluntary health agencies and others have led to inefficient use of medical faculty teachers. The key parties in continuing medical education—practitioner and teacher—can learn best in medical school-administered programs, which need be supported by all other interested organizations.     

Post Kala-Azar Dermal Leishmaniasis following Treatment with 20 mg/kg Liposomal Amphotericin B (Ambisome) for Primary Visceral Leishmaniasis in Bihar,India

Background

The skin disorder Post Kala-Azar Dermal Leishmaniasis (PKDL) occurs in up to 10% of patients treated for visceral leishmaniasis (VL) in India. The pathogenesis of PKDL is not yet fully understood. Cases have been reported in India following therapy with most available treatments, but rarely in those treated with liposomal amphotericin B (Ambisome). Between July 2007 and August 2012 with the support of the Rajendra Memorial Research Institute (RMRI), Médecins Sans Frontières (MSF) supported a VL treatment programme in Bihar, India—an area highly endemic for Leishmania donovani—in which 8749 patients received 20 mg/kg intravenous Ambisome as first-line treatment. This study describes the characteristics of patients who returned to the MSF supported treatment programme with PKDL.

Methods and Principal Findings

Over a 5-year period, Ambisome was administered to 8749 patients with laboratory-confirmed VL (clinical signs, rK39 positive, with/without parasite confirmation) in four intravenous doses of 5 mg/kg to a total of 20 mg/kg, with a high initial-cure rate (99.3%) and low default rate (0.3%). All patients received health education highlighting the possibility and symptoms of developing PKDL, and advice to return to the MSF programme if these symptoms developed. This is an observational retrospective cohort study of the programme outcomes. Of the 8311 patients completing treatment for their first episode of VL, 24 (0.3%) returned passively to the programme complaining of symptoms subsequently confirmed as PKDL, diagnosed from clinical history, appearance consistent with PKDL, and slit-skin smear examination. Of the 24 patients, 89% had macular lesions, with a median time (interquartile range) to development of 1.2 (0.8–2.2) years following treatment. Comparison of the demographic and clinical characteristics of the VL patients treated with Ambisome who later developed PKDL, with those of the remaining cohort did not identify any significant risk factors for PKDL. However, the time to developing PKDL was significantly shorter with Ambisome than in a subset of patients presenting to the programme with PKDL following previous sodium stibogluconate treatment for VL.

Conclusions

In this large cohort of patients with VL in Bihar who were treated with 20 mg/kg Ambisome, PKDL following treatment appears to be infrequent with no predictive risk factors. The shorter median time to developing symptoms of PKDL compared with that after conventional VL treatments should be taken into account when counseling patients treated with regimens including Ambisome.     

CHANGING CONCEPTS IN MEDICAL TREATMENT

In a community—even a small one—where physicians established in practice have intensity of purpose, continuing curiosity, healthy skepticism and the spirit of research, the medical atmosphere is one to attract and welcome young physicians who are recently graduated and eager to apply the knowledge gained from the specialists who taught them in medical schools.As the modern laboratory and other facilities and equipment now in use in teaching institutions become available in more and more small communities, general practice remote from the medical centers probably will have increasing allure for neophyte physicians upon whom great influence is being brought to bear to induce them to practice medicine where the need is greatest.Knowledge of the changes in concepts of medical treatment that have taken place in the life-span of the physicians already established in a community will help the young physician fit himself congenially and effectively into the methods of practice of his elder colleagues, with mutual benefit.     

Genetic pest management and the background genetics of release strains

Genetic pest management (GPM) methods involve releasing modified versions of a pest species to mate with wild pests in the target area. Proposed for a wide range of applications in public health, agriculture and conservation, most progress has been made with pest insects. Offspring of the released modified insects and wild pests carry the modification—which might be transgenes, artificially introduced Wolbachia or genetic damage from radiation, for example—but they also carry a complete haploid genome from their laboratory-reared parent, as well as one from their wild parent. Unless these F₁ hybrids are completely unable to reproduce, further mating will lead to introgression of DNA sequences from the release strain into the wild population. We discuss issues around strain selection and the potential consequences of such introgression. We conclude that such introgression is probably harmless in almost all circumstances, and could, in theory, provide specific additional benefits to the release programme. We outline population monitoring approaches that could be used, going forward, to determine how background genetics may affect GPM.This article is part of the theme issue ‘Novel control strategies for mosquito-borne diseases’.     

ATTITUDES TOWARD THE DUBIOUS COMPENSATION CLAIM

Laws providing for compensation of workmen for occupational injury are a powerful socio-economic force.In settlement of compensation claims the goal, difficult to achieve, is fairness to employee, employer and insurance carrier. Often, medical, legal, economic and social considerations conflict with one another. A “fact” in one field may not be considered so in another.Since medical data and testimony often guide the ultimate decision of a compensation claim, the physician''s attitude is a large factor not only immediately and directly in determination of the case at hand but, perhaps more important, in the ultimate direction of the socio-economic forces which spring from the sum of all such determinations.To perpetuate the good in workmen''s compensation laws, the next generation of physicians—and of lawyers and business administrators as well, for they, too, are involved—ought to have basic training in the social sciences in order that they may have a broad rather than a segmental view of the problems with which they deal.     

Surgical aspects of international drug smuggling

The internal concealment of cocaine and other drugs in packets by “body packers”—those who swallow packets of drugs or hide them in their vagina or rectum—to avoid detection by customs officials has been increasing in both the United States and Europe. The types of package and how they are concealed are changing as the traffickers become more sophisticated in their methods. The latest parcels are less likely to burst, but obstruction of the bowel may occur.Awareness of the problem is important for staff of emergency medical services near international ports of arrival.     

Specificity of Exercise in Exercise-induced Asthma

Ventilatory function after three types of exercise—running, cycling, and swimming—was studied in 10 control subjects and 40 asthmatic patients. All performed eight minutes of submaximal aerobic exercise during each of the programmes, which were conducted in a randomly selected order. Biotelemetric monitoring of heart rates was used to equate the intensity of the exertion undertaken during the three systems of exercise. No control subject showed any significant variation in ventilatory capacity after exercise, and the responses after the three forms of exercise did not differ.In asthmatics exercise-induced asthma was observed after 72·5% of running tests, 65% of cycling tests, and 35% of swimming tests. In addition, those patients who developed exercise-induced asthma after swimming were noted to have significantly smaller falls in FEV₁ levels than were recorded after running and cycling. These results were statistically significant (P <0·01).The unexplained aetiology of increased airways resistance after exercise in asthmatics is discussed. This study indicates that swimming should be recommended in preference to running or cycling as an exercise programme for adults and children with asthma.     

Electrolyte,Blood Urea Nitrogen and Glucose Level Screening in Medical Admissions: Impact on Patient Management

Investigators have failed to show the usefulness of screening electrolyte—sodium, potassium, chloride and bicarbonate—blood urea nitrogen and glucose levels. In spite of this, we observed that that practice continues to be widely used at our university medical center. Using a form of consensus analysis, we examined the records of 301 admissions to the medicine service to determine whether laboratory tests were done for diagnostic or screening purposes and whether screening test results led to changes in patient management. Of the 1,764 tests done, 716 (40.6%) were for screening purposes. Only 2 (0.3%) screening test abnormalities led to any therapeutic changes, and many false-positive tests led to unnecessary diagnostic retesting.     

A framework for feature extraction from hospital medical data with applications in risk prediction

Background

Feature engineering is a time consuming component of predictive modeling. We propose a versatile platform to automatically extract features for risk prediction, based on a pre-defined and extensible entity schema. The extraction is independent of disease type or risk prediction task. We contrast auto-extracted features to baselines generated from the Elixhauser comorbidities.

Results

Hospital medical records was transformed to event sequences, to which filters were applied to extract feature sets capturing diversity in temporal scales and data types. The features were evaluated on a readmission prediction task, comparing with baseline feature sets generated from the Elixhauser comorbidities. The prediction model was through logistic regression with elastic net regularization. Predictions horizons of 1, 2, 3, 6, 12 months were considered for four diverse diseases: diabetes, COPD, mental disorders and pneumonia, with derivation and validation cohorts defined on non-overlapping data-collection periods.For unplanned readmissions, auto-extracted feature set using socio-demographic information and medical records, outperformed baselines derived from the socio-demographic information and Elixhauser comorbidities, over 20 settings (5 prediction horizons over 4 diseases). In particular over 30-day prediction, the AUCs are: COPD—baseline: 0.60 (95% CI: 0.57, 0.63), auto-extracted: 0.67 (0.64, 0.70); diabetes—baseline: 0.60 (0.58, 0.63), auto-extracted: 0.67 (0.64, 0.69); mental disorders—baseline: 0.57 (0.54, 0.60), auto-extracted: 0.69 (0.64,0.70); pneumonia—baseline: 0.61 (0.59, 0.63), auto-extracted: 0.70 (0.67, 0.72).

Conclusions

The advantages of auto-extracted standard features from complex medical records, in a disease and task agnostic manner were demonstrated. Auto-extracted features have good predictive power over multiple time horizons. Such feature sets have potential to form the foundation of complex automated analytic tasks.

Electronic supplementary material

The online version of this article (doi:10.1186/s12859-014-0425-8) contains supplementary material, which is available to authorized users.     

Double-blind Evaluation of Verapamil,Propranolol, and Isosorbide Dinitrate against a Placebo in the Treatment of Angina Pectoris

In the treatment of angina pectoris a double-blind evaluation of verapamil (Cordilox) at two dose levels—namely, 80 mg thrice daily and 120 mg thrice daily—propranolol (Inderal) 100 mg thrice daily, and isosorbide dinitrate (Vascardin) 20 mg thrice daily has been made against a placebo. The assessment was based on relief from daily attacks of angina on effort and the response to a whole-body exercise test. We can find no statistically significant difference between the effects of verapamil (120 mg three times a day) and propranolol (100 mg three times a day) in the treatment of angina of effort. Both of these preparations are more effective than a placebo both in the reduction of daily attacks (P < 0·01) and in the prolongation of exercise test (P < 0·05). Isosorbide dinitrate (20 mg three times a day) appears to be no more effective than a placebo in the treatment of angina on effort, but 14 out of 32 patients experienced headache of such severity that even when the dose was reduced to 10 mg thrice daily this drug therapy had to be withdrawn. Both propranolol (100 mg three times a day) and verapamil (120 mg three times a day) had a significant lowering effect on the diastolic blood pressure as measured with the patient standing (P < 0·01).     

INDUSTRY CALLING!—Is There a Doctor in the House?

Medical service is needed in industry by both management and labor as never before. Industry is just beginning to awaken to this need. The medical profession is largely unaware of it. Unless physicians are prepared to heed this call, there is danger that management and labor will come to a bipartisan agreement over the bargaining table which will specify the amount, quality, and price of medical service irrespective of the effects of such an agreement on the practice of medicine. Such agreements should invariably be tripartite—between management, labor and medicine—if we are to continue to strive for medicine''s traditional ideals: The best of medical care for all alike.This situation imposes at least two important obligations on organized medicine at the national level and especially at state and local levels where there is industrial concentration:1. Provision of a strong and competent committee or council whose members are especially interested in occupational medicine and who will make their presence known to management and labor alike, offering to advise with them on all medical problems, to mediate their disagreements or medical questions, and to help them attain a common goal.2. Assisting the members of organized medicine who are interested, to learn more about the medical problems peculiar to occupational health.