A methodology for evaluation of knowledge-based systems in medicine

Evaluation is critical to the development and successful integration of knowledge-based systems into their application environment. This is of particular importance in the medical domain--not only for reasons of safety and correctness, but also to reinforce the users' confidence in these systems. In this paper we describe an iterative, four-phased development evaluation cycle covering the following areas: (i) early prototype development, (ii) validity of the system, (iii) functionality of the system, and (iv) impact of the system.

Transsarcolemmal movement of inorganic phosphate in glucose-perfused rat heart: a 31P nuclear magnetic resonance spectroscopic study

Fluxes of orthophosphate (Pi) across the sarcolemma may be important in myocardial metabolism, yet little is known of these in the intact heart. We used 31P NMR spectroscopy to measure net Pi fluxes from changes in the concentrations of Pi, phosphocreatine (PCr), ATP and "total phosphate" ([TP] = [PCr] + 3[ATP] + [Pi]) in the isolated perfused rat heart in response to a change in extracellular [Pi] from 2 mM to 0 mM. [Pi] decreased to 62% of control with a half-time of 6 min, while [TP] decreased with initial rate 20 mM/h, a measure of net Pi efflux. As [PCr] decreased to 83% of control, phosphorylation potential remained constant. Contractile function was unaffected. Reperfusion with 2 mM Pi reversed all changes, causing net Pi influx at 26 mM/h. Analysed according to a model of net Pi flux, these imply a sarcolemmal permeability rate constant of 13 per h. Insulin in the 2 mM Pi perfusion buffer caused a transient decrease in intracellular [Pi] to 59% of control, while [TP] increased, giving a net Pi influx of 12 mM/h and a permeability constant of 12 per h. [PCr] increased by 28% over 34 min. Thus, insulin caused Pi influx by stimulating Pi incorporation into organic phosphates, transiently decreasing intracellular [Pi] and increasing the outside-to-inside [Pi] gradient. The response to 0 mM and 2 mM Pi perfusion was unaffected by insulin. We conclude that Pi fluxes across the sarcolemma are substantial and may have implications for Pi-free tissue perfusion and clinical hypophosphataemia.

Interpretative reporting and alarming based on laboratory data

The utilisation of laboratory services for patient diagnosis and management involves many steps with both clinical and laboratory components. The clinical components include the decision to order a test, interpretation of the test results and actions taken on the basis of the results. The laboratory components on the other hand include receipt of the request, specimen collection, preparation and analysis, result entry, test result validation and verification and reporting of the results. In this paper, which is part of the OpenLabs project, we concentrate on the post-analytical applications which include interpretation and reporting of the laboratory results to the users in primary care and in high dependency care units. The final objective of the work described is to develop generic modules which can be integrated both with an Open laboratory information system architecture and existing laboratory information processing environment.

Lipid accumulation in isolated perfused rat hearts has no apparent effect on mechanical function or energy metabolism as measured by 31P NMR

Male Sprague-Dawley rats were fed diets that contained 20% by weight soybean oil or rapeseed oil (21% and 43% erucic acid) for 7 days. The rapeseed oil diets increased the cardiac triacylglycerol content 5-fold and 25-fold, respectively, above control values. Hearts were removed from the animals and perfused with modified Krebs-Henseleit buffer at 37 degrees C. The calculated rate-pressure product was used as a measure of contractile function. 31P NMR spectra were acquired throughout a protocol that consisted of 12 min control perfusion, followed by 12 min perfusion with 20 microM isoproterenol, 12 min washout, 12 min total global ischemia, and 28 min reperfusion. The steady state levels of creatine phosphate, ATP, intracellular pH, contractile function, and the free energy of ATP hydrolysis (delta GATP) were determined for all three groups of hearts. Isoproterenol more than doubled the rate-pressure product of the hearts on all diets and decreased the concentrations of creatine phosphate and ATP with a concomitant rise in Pi. After global ischemia, creatine phosphate levels recovered fully, ATP levels remained low, and most hearts developed ventricular fibrillation. Changes in intracellular pH were the same for all groups: pH was 7.1 throughout the equilibration and isoproterenol perfusion period, decreased to pH approximately 6.4 during ischemia, and returned to 7.0 during reperfusion. The results indicate that the fat accumulation that occurs in the hearts of rats fed diets rich in high erucic acid rapeseed oil does not interfere with the cardiac high energy phosphate metabolism or contractile function.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracellular volume and transsarcolemmal proton movement during ischemia and reperfusion: a 31P NMR spectroscopic study of the isovolumic rat heart

We have measured, directly and simultaneously, changes in extracellular volume and intra- and extracellular pH during ischemia in the isolated rat heart using 31P NMR spectroscopy. Hearts were perfused with buffer containing 15 mM sodium phenylphosphonate at pH 7.4. Wash in and wash out experiments showed that phenylphosphonate entered only the extracellular (interstitial, vascular and chamber) space of the heart and had no adverse effects on myocardial energetics, contractile function or coronary flow rate. Hearts were subjected to 28 min of total, global ischemia, during which the phenylphosphonate resonance area in the 31P NMR spectra decreased by 83%, indicating that extracellular fluid had moved rapidly from the heart to the bath surrounding the heart, partly as a result of vascular collapse. A separate, morphological study confirmed that 95% of the vasculature had collapsed by 28 min ischemia. Intra- and extracellular pH were determined from the chemical shifts of the P(i) and the phenylphosphonate resonances, respectively. In the pre-ischemic rat heart, intracellular pH was 7.15 +/- 0.03 and extracellular pH was 7.39 +/- 0.03. By 4 min of ischemia, intra- and extracellular pH were the same and decreased concomitantly throughout the remainder of ischemia to final values of 6.09 +/- 0.19 and 6.16 +/- 0.23, respectively. On reperfusion, the extracellular volume and pH returned to pre-ischemic levels within 1 min, but restoration of intracellular pH took > 2.5 min. Thus, a large volume of extracellular fluid moves out of the rat heart to the surrounding bath and the intra- and extracellular pH become the same during total, global ischemia.

Paternal preconceptional radiation exposure in the nuclear industry and leukaemia and non-Hodgkin's lymphoma in young people in Scotland

OBJECTIVE

To determine if a relation exists between paternal exposure to relatively high levels of radiation in the Scottish nuclear industry and the risk of leukaemia and non-Hodgkin's lymphoma is subsequently conceived children.

DESIGN

Matched case-control study with three controls for each case.

SETTING

The whole of Scotland.

SUBJECTS

The fathers of 1024 children with leukaemia and 237 children with non-Hodgkin's lymphoma diagnosed in Scotland below the age of 25 among those born in Scotland since nuclear operations began (in 1958) and the fathers of 3783 randomly chosen controls. The fathers of 80 children with leukaemia and 16 with non-Hodgkin's lymphoma in north Cumbria were also covered since some workers at one Scottish nuclear site live over the border in that area. Details of all fathers were then matched against records of the nuclear industry.

MAIN OUTCOME MEASURES

Paternal preconceptional radiation exposures, particularly relatively high levels, both lifetime and in the six and three months before conception.

RESULTS

No significant excess was observed in any subgroup and there was no significant trend: fathers of three controls but no cases were exposed to lifetime preconceptional levels of 100 mSv or greater (Fisher's exact p value 0.84). In the six months before conception, fathers of two cases and three controls received 10 mSv or more, odds ratio 2.3 (95% confidence interval 0.31 to 17.24). In the three months before conception the fathers of one case and two controls received 5 mSv or more, odds ratio 1.7 (0.10 to 30.76). The results for leukaemia and non-Hodgkin's lymphoma combined were similar.

CONCLUSIONS

No significant excess of leukaemia or of leukaemia and non-Hodgkin's lymphoma was found at any radiation level in any preconceptional period.

Microalbuminuria does not predict cardiovascular disease in a normal general practice population

Recent studies have suggested that microalbuminuria is relatively common (9.4%) in non-diabetic subjects and that it is an excellent marker for increased cardiovascular risk. In an attempt to assess the prevalence of microalbuminuria in Northern Ireland where there is a high incidence of coronary heart disease, we studied 400 males, age 35-65 years, chosen at random from a Belfast general practice. There was a 73% response rate (n = 273). Sixteen per cent of the population has ischaemic heart disease. Microalbuminuria was defined as an increased urinary albumin excretion rate of 20-200 ug min-1. Thirteen subjects (4.7%) had an albumin excretion rate of 20 ug min-1 or more. After exclusion of subjects with diabetes mellitus or renal diseases, the group with microalbuminuria (n = 8), was compared to those without microalbuminuria (n = 256). There was no significant difference in the incidence of ischaemic heart disease between the two groups, nor did the group with microalbuminuria have a more adverse profile of vascular risk factors, apart from serum triglyceride (1.8 +/- 0.2 v 1.3 +/- 0.0 mmol l-1, p < 0.05) and plasma glucose (5.5 +/- 0.3 v 5.1 +/- 0.3 mmol l-1, p < 0.05) levels. We conclude that in a general practice from an area at high risk of ischaemic heart disease, the prevalence of microalbuminuria was low. Contrary to previous reports, microalbuminuria was not helpful in predicting subjects at risk of ischaemic heart disease.

Rural population mixing and childhood leukaemia: effects of the North Sea oil industry in Scotland, including the area near Dounreay nuclear site

OBJECTIVE

To determine if any excess of childhood leukaemia and non-Hodgkin's lymphoma was associated with certain striking examples of population mixing in rural Scotland produced by the North Sea oil industry.

DESIGN

Details were traced for over 30,000 workers involved in the construction of the large oil terminals in the Shetland and Orkney islands in northern Scotland or employed offshore. Home addresses of the 17,160 Scottish residents were postcoded, integrated with census data, and then classified as urban or rural. Rural postcode sectors, ranked by proportion of oil workers, were grouped into three categories with similar numbers of children but contrasting densities of oil workers. The incidence of leukaemia and non-Hodgkin's lymphoma was examined in these rural (and also in urban) categories in the periods 1974-8, 1979-83 and 1984-8.

SETTING

Scotland.

SUBJECTS

Young people below age 25.

RESULTS

A significant excess of leukaemia and non-Hodgkin's lymphoma was found in 1979-83 in the group of rural home areas with the largest proportion of oil workers, following closely on large increases in the workforce. The area near the Dounreay nuclear installation, where an excess of leukaemia is already well known, was within the rural high oil category.

CONCLUSION

The findings support the infection hypothesis that population mixing can increase the incidence of childhood leukaemia in rural areas. They also suggest that the recent excess in the Dounreay-Thurso area is due to population mixing linked to the oil industry, promoted by certain unusual local demographic factors.

Renal artery stenosis: current diagnosis and treatment

OBJECTIVE

To provide an overview of the current approaches to management of renovascular disease.

DATA SOURCES

A literature review was performed and key references are provided relating to diagnostic tests, particularly captopril renography and renal duplex scanning. Options for treatment are reviewed from published series to December 1991. We also draw on the experience of our own Unit.

STUDY SELECTION

Data and opinions from five general reviews of renovascular disease, 10 articles on diagnostic tests and five articles relating to therapeutic approaches are summarised.

CONCLUSION

There is no simple screening test for renovascular hypertension that can be applied to an unselected population of hypertensive subjects. The diagnosis depends on judicious use of non-invasive screening tests in those subjects in whom one suspects, on clinical grounds, that there may be an underlying renovascular lesion. Captopril renography and duplex scanning of renal arteries are the most reliable non-invasive screening tests. A team approach with collaboration of hypertension specialist/vascular physician, vascular surgeon and experienced interventional radiologist is important for rational management and we would emphasise the importance of audit procedures.

A stimulatory Mls-1 superantigen is destroyed by ultraviolet light while other Mtv-7 antigens remain intact. Significance for Mls-1 unresponsiveness

Accessory cells present Ag together with costimulatory signals as immunogens and without costimulatory signals as tolerogens. Responsiveness and unresponsiveness are thus alternatives of T cell immune reactions to Ag. Superantigens appear to make an exception; being presented by accessory cells capable of providing costimulatory signals, these Ag induce a strong T cell response but leave T cells unresponsive to a secondary challenge (anergy). We show here that T cell anergy is not a mandatory consequence of superantigen-induced activation. Mls-1- BALB/c recipients of DBA/2 spleen cells mount vigorous Mls-1 responses in vivo but their T cells retain the ability to respond to a subsequent Mls-1 challenge in vitro. We tested the possibility that the inability of DBA/2 spleen cells to inactivate Mls-1-reactive BALB/c T cells was the result of excessive costimulatory activity provided by Mls-1+ DBA/2 B cells. Costimulatory accessory cell activity has been reported to be destroyed by UV light. We exposed superantigen-presenting cells to UV radiation and found that they had lost the ability to stimulate an Mls-1 response without, however, gaining the capacity to render Mls-1-specific T cells anergic. Despite their inability to noticeably stimulate Mls-1-reactive T cells, UV-treated Mls-1+ lymphocytes induced an absolute unresponsiveness in Mls-1- recipients to a second challenge with the superantigen. Our data are in agreement with previous evidence, confirmed here, that BALB/c mice establish immunity against Mls-1+ cells, which causes the accelerated rejection of superantigen-bearing lymphocytes. Thus, our data imply that, whereas it takes stimulatory superantigenic Mtv-7 gene products to induce the activation of superantigen-reactive T cells, nonsuperantigenic Mtv-7 gene products may induce an immune response leading to the elimination of Mtv-7+ lymphoid cells.

A stimulatory Mls-1 superantigen is destroyed by ultraviolet light while other Mtv-7 antigens remain intact. Significance for Mls-1 unresponsiveness

Accessory cells present Ag together with costimulatory signals as immunogens and without costimulatory signals as tolerogens. Responsiveness and unresponsiveness are thus alternatives of T cell immune reactions to Ag. Superantigens appear to make an exception; being presented by accessory cells capable of providing costimulatory signals, these Ag induce a strong T cell response but leave T cells unresponsive to a secondary challenge (anergy). We show here that T cell anergy is not a mandatory consequence of superantigen-induced activation. Mls-1- BALB/c recipients of DBA/2 spleen cells mount vigorous Mls-1 responses in vivo but their T cells retain the ability to respond to a subsequent Mls-1 challenge in vitro. We tested the possibility that the inability of DBA/2 spleen cells to inactivate Mls-1-reactive BALB/c T cells was the result of excessive costimulatory activity provided by Mls-1+ DBA/2 B cells. Costimulatory accessory cell activity has been reported to be destroyed by UV light. We exposed superantigen-presenting cells to UV radiation and found that they had lost the ability to stimulate an Mls-1 response without, however, gaining the capacity to render Mls-1-specific T cells anergic. Despite their inability to noticeably stimulate Mls-1-reactive T cells, UV-treated Mls-1+ lymphocytes induced an absolute unresponsiveness in Mls-1- recipients to a second challenge with the superantigen. Our data are in agreement with previous evidence, confirmed here, that BALB/c mice establish immunity against Mls-1+ cells, which causes the accelerated rejection of superantigen-bearing lymphocytes. Thus, our data imply that, whereas it takes stimulatory superantigenic Mtv-7 gene products to induce the activation of superantigen-reactive T cells, nonsuperantigenic Mtv-7 gene products may induce an immune response leading to the elimination of Mtv-7+ lymphoid cells.

Changes in probe sensitivity during NMR spectroscopic studies of the perfused rat heart: a warning

During NMR experiments on isolated, perfused rat heart, we observed a 57% change in probe sensitivity when the perfusion buffer surrounding the heart was replaced by either a low-ionic-strength mannitol solution or air and the heart was made ischemic. Such changes in sensitivity, should they go unrecognized, would result in substantial quantification errors.

Assessment of value of calibrated lyophilised plasmas to determine International Sensitivity Index for coagulometers

An attempt was made to correct for the effects of coagulometers on the International Sensitivity Index (ISI) in a series of collaborative studies. Modified ISI were derived from the prothrombin time results with coagulometer systems using a range of calibrated plasmas. Two alternative approaches to correction of the ISI were evaluated. The first relied on the consensus orthogonal regression slopes of the prothrombin times for each coagulometer system plotted against the consensus manual results; the second depended on the local individual slope of the prothrombin times for each instrument. The two procedures were compared with the currently recommended method where International Normalised Ratios (INR) are derived from the manual ISI of the thromboplastin. The recommended method gave a significant bias from the manual results with most coagulometers. In contrast, the local correction procedure gave no significant biases, whereas the consensus method did so in a few instances. Both these correction procedures seem more reliable than the recommended method of INR derivation, but the local correction is more accurate and offers a more practical solution by allowing laboratories to determine their own corrected ISI on a range of calibrated plasmas.

Control of endemic nosocomial legionnaires' disease by using sterile potable water for high risk patients

In a setting where potable water is contaminated with Legionella pneumophila serogroup 1, we performed two case control studies. The first case control study consisted of 17 cases of nosocomial Legionnaires' disease (LD) and 33 control (the patients who were admitted to the ward where the case was admitted immediately before and after the case) subjects. Cases had a higher mortality rate 65% vs 12% (P less than 0.004); were more likely to have received assisted ventilation (P less than 0.00001); to have nasogastric tubes (P less than 0.0004) and to be receiving corticosteroids or other immunosuppressive therapy (P less than 0.0001). Based on the results of this study, sterile water was used to flush nasogastric tubes and to dilute nasogastric feeds. Only 3 cases of nosocomial LD occurred during the next year compared with 12 the previous year (P less than 0.0001). Nine cases subsequently occurred and formed the basis for the second case-control study. Eighteen control subjects were those patients admitted to the same unit where the case developed LD, immediately before and after the case. The mortality rate for the cases was 89% vs 6% for controls (P less than 0.00003). The only other significant difference was that cases were more likely to be receiving corticosteroids or other immunosuppressive therapy 89% vs 39% (less than 0.01). We hypothesized that microaspiration of contaminated potable water by immunocompromised patients was a risk factor for nosocomial Legionnaires' disease. From 17 March 1989 onwards such patients were given only sterile potable water. Only two cases of nosocomial LD occurred from June 1989 to September 1990 and both occurred on units where the sterile water policy was not in effect. We conclude that aspiration of contaminated potable water is a possible route for acquisition of nosocomial LD in our hospital and that provision of sterile potable water to high risk patients (those who are receiving corticosteroids or other immunosuppressive drugs; organ transplant recipients or hospitalized in an intensive care unit) should be mandatory.

Indium-111-leukocyte imaging in acute cholecystitis

Eleven patients with suspected acute cholecystitis underwent sequential 99mTc-iminodiacetic derivative (IDA) and 111In-white blood cell (WBC) imaging to determine if 111In-WBCs accumulate within an acutely inflamed hemorrhagic gallbladder wall and, thus, could be employed as a reasonable alternative to 99mTc-IDA scintigraphy in detecting acute cholecystitis. Seven patients had surgically confirmed acute cholecystitis. Of these cases, five had a true-positive 99mTc-IDA and 111In-WBC, one an indeterminate 111In-WBC and true-positive 99mTc-IDA, and one a true-positive 111In-WBC and false-negative 99mTc-IDA scan. The remaining four patients did not have acute cholecystitis. All visualized their gallbladder within 1 hr after 99mTc-IDA administration and none had 111In-WBC gallbladder wall uptake. Both 111In-WBC and 99mTc-IDA scintigraphy accurately detected acute cholecystitis: hepatobiliary scintigraphy demonstrated a cystic duct obstruction and 111In-WBC imaging detected the inflammatory infiltrate within the gallbladder wall. The sensitivity and specificity of each was 86% and 100%, respectively.

Nosocomial legionnaires' disease: lessons from a four-year prospective study

We studied all cases of nosocomial pneumonia at our 800-bed tertiary care hospital from September 1983 to September 1987. Of the 813 cases of nosocomial pneumonia, 31 (3.8%) were definite (isolation of organism or fourfold rise in titer) and 21 (2.5%) were possible cases (single or stable antibody titer of greater than or equal to 1:256) of legionnaires' disease. The definite cases involved a more severe form of pneumonia and a significantly higher mortality rate--64% versus 14% (p less than 0.0009) compared with the possible cases. Despite attempted comprehensive surveillance, only four (13%) of the definite cases of legionnaires' disease were found that would not have been diagnosed if the study were not ongoing. The yield from adequate (4- to 6-week convalescent serum samples) serologic testing was 5%, whereas the yield from sputum culture was 11%. We conclude that targeted surveillance of immunosuppressed patients with nosocomial pneumonia by culture of respiratory tract secretions for Legionella pneumophila is adequate for monitoring for the presence of legionnaires' disease in a hospital.

Analysis of 23Na NMR spectra from isolated perfused hearts

The 23Na NMR spectra obtained from isolated hearts perfused with buffer containing the paramagnetic shift reagent dysprosium triethylenetetraminehexaacetic acid, Dy(TTHA)3-, are complex and contain a number of overlapping peaks of different intensities. Spectra from rat, rabbit, guinea pig, and ferret hearts obtained during periods of control perfusion are similar and undergo similar changes when the hearts are subjected to periods of ischemia and reflow. The contributions from the intracellular, interstitial, vascular, and bath compartments to the multiple peaks in the spectra of rats hearts have been assigned. The significant contributions to these spectra of bulk magnetic susceptibility effects and incomplete mixing have been demonstrated through a series of modeling experiments. Since the spectra from hearts of different species are so similar, the peak assignments made for the rat are applicable to spectra from rabbit, guinea pig, and ferret hearts as well. This work provides a framework for quantitative analysis of the spectral changes which occur during conditions such as ischemia and reflow.

NHS review. Kenneth Clarke: hatchet man or remoulder. Interview by John Roberts

Images