Natural language generation in health care

Good communication is vital in health care, both among health care professionals, and between health care professionals and their patients. And well-written documents, describing and/or explaining the information in structured databases may be easier to comprehend, more edifying, and even more convincing than the structured data, even when presented in tabular or graphic form. Documents may be automatically generated from structured data, using techniques from the field of natural language generation. These techniques are concerned with how the content, organization and language used in a document can be dynamically selected, depending on the audience and context. They have been used to generate health education materials, explanations and critiques in decision support systems, and medical reports and progress notes.

Decrease in expenditures and selected nosocomial infections following implementation of an antimicrobial-prescribing improvement program

OBJECTIVE

To evaluate changes in antimicrobial use and expenditures and the rates of selected nosocomial infections due to resistant organisms associated with implementation of an antimicrobial-prescribing improvement program.

DESIGN

Before-after trial comparing 1992 (pre-program), 1993 (a transition year), and 1994 (after full implementation of the program).

SETTING AND PARTICIPANTS

Academic medical center, all patients and physicians.

INTERVENTION

An antimicrobial-prescribing improvement program with prior approval requirement for use of restricted agents.

MAIN OUTCOME MEASURES

Antimicrobial use and expenditures, rates of selected nosocomial infection marker events.

RESULTS

Between 1992 and 1994, there were substantial decreases in antimicrobial use, from 158,107 to 137,364 defined daily doses, and in expenditures from $2,486,902 ($24.01 per patient day) to $1,701,522 ($18.49 per patient day). After adjusting for changes in purchase prices and census days, we estimated savings attributable to the program of $279,573 in 1993 and $389,814 in 1994. In addition, we found significant decreases between 1992 and 1994 in the rates of enterococcal bacteremia (.34 vs .16 events per 1,000 patient days; P = .016), selected gram-negative bacteremia (.26 vs .11; P = .015), methicillin-resistant Staphylococcus aureus colonization or infection (.66 vs .20; P < .0001), and Stenotrophomonas colonization or infection (.35 vs .17; P = .019). No significant change occurred in rates of nosocomial candidemia or Clostridium difficile toxin-positive diarrhea. Values for 1993 were intermediate between those of 1992 and 1994.

CONCLUSION

Implementation of an antimicrobial-prescribing improvement program was associated with substantial savings in antimicrobial use and expenditures and significant decreases in rates of selected nosocomial infections due to resistant organisms.

Changes in tonic immobility and the GABA-benzodiazepine system in response to handling in the chick

Changes in the GABA-benzodiazepine system were investigated following regular handling of male chicks. Compared with handling-naive chicks, those exposed to 10 days of gentle handling required a larger number of inductions and had a lower duration of tonic immobility. Corresponding biochemical changes occurred, with handling-habituated chicks having a significantly lower basal [14C]GABA release from archistriatal slices and a reduction in the Bmax of [3H]muscimol binding in the forebrain. Benzodiazepine binding in the archistriatum was investigated using in vitro quantitative receptor autoradiography. Binding was localised in the anterior, mediale, dorsalis, and ventralis intermedium nuclei of the archistriatum, and there was significantly more binding in the anterior and ventralis intermedium/mediale archistriatum nuclei than in the dorsalis intermedium archistriatum nuclei. Benzodiazepine binding was not altered after handling in any of the investigated nuclei of the archistriatum. The results suggest that whereas several days of gentle handling in chicks leads to a decrease in forebrain GABAA receptors and a decrease in GABA release from the archistriatum, there are no accompanying changes in benzodiazepine receptors. Regular handling exerts a specific effect on chicks: it reduces their fear or human beings but not that of novel places or objects. It is possible that the pattern of biochemical changes observed in the present study may be specifically associated with this particular behavioural modification rather than with a change in general fearfulness.

Evaluation of the Vidas Chlamydia test to detect and verify Chlamydia trachomatis in urogenital specimens

The Vidas Chlamydia test (CHL) is an automated enzyme-linked immunofluorescence assay for the detection of Chlamydia trachomatis. Positive and equivocal results are confirmed with a blocking assay. A mouse monoclonal antibody directed against the chlamydial lipopolysaccharides was used for the test. The CHL assay is widely used in Europe, but U.S. experience with it is limited. Three clinical test sites (The Arlington Hospital, Arlington, Va., Indiana University, Indianapolis, and the University of California, San Francisco) compared CHL with tissue culture (TC) for the identification of chlamydia in urogenital specimens (2,453 females and 850 males). True positives (TP) were defined as either TC positive or TC negative and CHL positive by a positive direct fluorescent-antibody assay or PCR test. Overall prevalence was 5.5% for females, 10.3% for male urethral swabs, and 10.7% for combined male TC urethral swabs and CHL with first catch urine (FCU) specimens. Compared to TP, CHL and TC had sensitivities of 89.6 and 94.1% with female cervical swabs and 90.9 and 86.4% with male urethral swabs, respectively. CHL sensitivity was 81.2 for male FCU specimens and 77.7% for matching male TC swabs. There were relatively few false-positive results, with all specificities being >99.4%. With the blocking assay, Vidas CHL specificity was >99.7%. However, male FCU specimen sensitivity was compromised because 9.2% (7 of 76) of the TP were initially positive but were not confirmed. An improvement in the Vidas blocking assay is needed before we can recommend its use with male urine. Alternatively, one could argue that the specificity of the test is so high that a confirmatory assay is not needed. For male and female swabs, the Vidas CHL assay has a performance that is similar to that of TC.

Comparison of single-dose oral grepafloxacin with cefixime for treatment of uncomplicated gonorrhea in men. The STD Study Group

In a randomized open study, 351 male patients with uncomplicated gonorrhea were given single oral doses of grepafloxacin (400 mg) or cefixime (400 mg). In the 299 microbiologically evaluable patients, urethral infections were cured in 99% (147 of 149) of those receiving grepafloxacin and 97% (145 of 150) of those given cefixime. Eradication rates for both regimens were 100% in the 16% (47 of 299) of participants who were infected with penicillin-resistant Neisseria gonorrhoeae and 97% in the 21% (62 of 299) of participants infected with tetracycline-resistant strains. Grepafloxacin is a well-tolerated alternative to cefixime for treatment of uncomplicated gonorrhea in males.

Susceptibility of Chlamydia trachomatis to trovafloxacin

Chlamydia trachomatis infections are a major cause of morbidity in the sexually active. While current therapy is usually effective, isolates demonstrating relative resistance to erythromycin or heterotypic resistance to erythromycin, tetracycline and their congeners have been described, establishing a need to continue to evaluate other antimicrobial agents for possible efficacy. In this study trovafloxacin, a compound related to the fluoroquinolones, was tested in tissue culture for in-vitro efficacy against 19 strains of C. trachomatis, including three strains known to exhibit heterotypic resistance. All strains were fully sensitive to trovafloxacin with a minimum inhibitory concentration at which 90% of inclusions were reduced (IR90) of 0.05 +/- 0.07 mg/L (mean +/- S.D.). The IR90 for the comparison antibiotics erythromycin, doxycycline and ofloxacin were 0.17 +/- 0.07, 0.10 +/- 0.03 and 0.35 +/- 0.15 mg/L respectively. Trovafloxacin is very active on a weight basis and deserves further evaluation.

Evaluation of BTS 67 582, a novel antidiabetic agent, in normal and diabetic rats

1. The effect of BTS 67 582, a novel antidiabetic agent, has been evaluated on plasma glucose and plasma insulin in normal and streptozotocin-induced diabetic rats. 2. BTS 67 582 (3 to 300 mg kg-1, p.o.) caused a dose- and time-dependent reduction in plasma glucose and an increase in plasma insulin in both fasted and glucose-loaded normal rats. The ED50 for the glucose lowering effect of BTS 67 582 in fasted rats was 37.6, 18.4 and 18.5 mg kg-1 at 1, 2 and 4 h after administration respectively. 3. In streptozotocin-induced (50 mg kg-1, i.v.) diabetic rats, BTS 67 582 (37-147 mg kg-1, p.o.) caused significant reductions of plasma glucose following a glucose load, whereas glibenclamide (100 mg kg-1, p.o.) was ineffective. BTS 67 582 significantly increased plasma insulin compared to controls whereas glibenclamide did not. 4. BTS 67 582 did not displace [3H]-glibenclamide from its binding sites in rat brain, guinea-pig ventricle or the HIT-T15 insulinoma beta-cell line. BTS 67 582 does not therefore appear to modulate its action via an effect on the 'sulphonylurea' receptor. 5. In fasted rats, the glucose lowering effect of BTS 67 582 (100 mg kg-1 p.o.) and glibenclamide (1 mg kg-1, p.o.) were antagonized by diazoxide (30 mg kg-1, i.p.). In addition BTS 67 582, like glibenclamide, caused a dose-dependent rightward shift of cromakalim-induced relaxation of noradrenaline precontracted rat aortic strips, suggesting the involvement of KATP channels. 6. In summary, BTS 67 582 produces a blood glucose-lowering effect in normal and streptozotocin-induced diabetic rats associated with increased insulin concentrations. This effect appears to be due to a blockade of ATP-sensitive potassium channel activity via a different binding site to that of glibenclamide.

Ease of capture in Japanese quail of two lines divergently selected for adrenocortical response to immobilization

Divergent lines of Japanese quail have been genetically selected over several generations for a reduced (low stress, LS) or an exaggerated (high stress, HS) plasma corticosterone response to brief mechanical restraint. Female quail were housed in one mixed-line group (18LS + 18 HS) in one of the top-tier compartments of a brooder. At 32 d of age, the quail were removed individually by the experimenter, their identity and position in the order of capture were noted, and then they were placed in a separate compartment. Following brief respites, this procedure was repeated on 16 occasions. No differences were found between HS and LS quail in their ease of capture and no linear trends were apparent upon repeated testing of either strain. These findings have positive connotations for management and welfare because, although selection for a reduced adrenocortical stress response to restraint has apparently been accompanied by reduced fearfulness, it has not resulted in a potential and undesirable increase in the difficulty of capture and handling. Further, the significant tendencies found within and across lines for individual birds to be caught at similar stages of each trial has important implications for behavioral studies that involve putatively random sampling of a population.

Psychogenic disorders of vision in childhood ("visual conversion reactions"): perspectives from adolescence: a research note

Fifteen adolescents who had exhibited psychogenic disorders of vision in childhood were compared with a control group of adolescents who had experienced childhood visual dysfunction of organic origin. The principal modes of assessment were clinical interviews, the Parental Bonding Instrument (PBI), and self-report measures concerning specific personality traits. Adolescents who had previously presented with psychogenic disorder were more likely to (1) report having experienced school difficulties and the loss of a significant figure at the time of presentation, (2) rate their mothers as over-involved on the PBI and (3) report adjustment difficulties and obsessional personality traits in adolescence.

Chlamydia trachomatis and febrile complications of postpartum tubal ligation

OBJECTIVE

Our goal was to determine whether chlamydia-infected women have a higher rate of febrile complications after postpartum tubal ligation.

STUDY DESIGN

Cross-sectional analysis of 1447 women tested for chlamydial infection within 2 weeks of delivery and who underwent postpartum tubal ligation was performed. Subjects were identified with the Regenstrief Institute for Health Care database. Infected subjects were compared with uninfected subjects for incidence of fever not explained by nongynecologic sources.

RESULTS

Women infected with Chlamydia trachomatis at delivery were more likely to experience febrile postoperative complications after tubal ligation (p < 0.0001, relative risk 9.5, 95% confidence interval 4.5 to 20.1).

CONCLUSION

Women undergoing postpartum tuba ligation may benefit from prompt diagnosis and preoperative treatment of chlamydial infection.

Peripheral blood stem cells for autografting

High-dose therapy with autologous hematopoietic progenitor cell support is effective treatment for patients with a variety of high-risk malignancies. Accelerating of marrow recovery from near-lethal or lethal toxicity with hematopoietic cell support improves the safety and cost effectiveness of the high-dose regimens. Peripheral blood progenitor cells will soon replace marrow as the major source of hematopoietic support. This chapter reviews the techniques of peripheral blood progenitor cell collection, mobilization, purification (for tumor removal), and ex vivo expansion.

Paclitaxel-containing high-dose chemotherapy: the University of Colorado experience

Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) is one of the most important antineo-plastic agents developed over the last 20 years. It has proven activity in breast cancer, ovarian cancer, and non-small cell lung cancer. In this study, the possibility of incorporating paclitaxel into a high-dose chemotherapy regimen targeting patients with breast cancer was evaluated. From a widely used regimen composed of cyclophosphamide, cisplatin, and carmustine, carmustine was deleted and paclitaxel added at the beginning of the regimen. The dose of paclitaxel was then escalated until life-threatening toxicities occurred. It was demonstrated that the dose of paclitaxel could be escalated to 775 mg/m2, combined with cyclophosphamide 5,625 mg/m2 and cisplatin 165 mg/m2, followed by autologous hematopoietic progenitor cell support. A phase II study testing this combination in patients with chemotherapy-responsive metastatic breast cancer has been initiated. A new phase I study to test the feasibility of adding carmustine to this paclitaxel-based regimen is currently under way. The status of this study is briefly summarized.

Do agoraphobics interpret the environment in large shops and supermarkets differently?

Agoraphobics typically have difficulties in visiting supermarkets. The brief report presents results of a survey investigating the properties of supermarkets which provoke or ease anxiety-related responses in shoppers (N = 500) and two further groups: agoraphobics (N = 40) and participants responding to a local press advert (N = 54). Results showed that layout features, stairways and diminished access were rated as more anxiety provoking in the agoraphobic-type groups compared to general shoppers. The safety-signal model of agoraphobic behaviour was supported although some evidence of dysfunction of spatial orientation was found.

High-dose chemotherapy with AHPCS for the treatment of breast cancer. The University of Colorado results

In summary, the administration of effective high-dose chemotherapy regimens at a time of minimal tumor burden should eradicate disease in selected breast cancer patients who otherwise have little chance of prolonged disease-free survival following standard-dose treatments. The results are particularly promising for breast cancer patients with high-risk stage II/III, and NED or responsive stage IV disease. Many studies to confirm these hypotheses are in progress. New high-dose chemotherapy regimens, together with methods to reduce tumor contamination of the graft and new treatment modalities should improve the current results in patients with breast cancer.

Renal function in high dose chemotherapy and autologous hematopoietic cell support treatment for breast cancer

Autologous and allogeneic bone marrow grafting both require cytoreductive therapy but only the allogeneic procedure requires immunosuppressive agents. Allogeneic bone marrow transplantation has been reported to be associated with a high incidence of both renal failure and veno-occlusive disease (VOD) of the liver, the combination of which is associated with a high morbidity and mortality. There is less known about the frequency and severity of these complications in patients undergoing autologous bone marrow transplantation. In the present study renal, hepatic and other complications were examined in 232 patients with Stages II/III and IV breast cancer who were treated with high-dose chemotherapy and autologous hematopoietic cell support with either marrow or peripheral blood progenitor cells. The post-treatment severity of the renal dysfunction was classified as follows: Grade 0, normal renal function [< 25% decrement in glomerular filtration rate (GFR)]; Grade 1. mild renal dysfunction (> 25% decrement in GFR but < a twofold increase in serum creatinine); Grade 2, > twofold rise in serum creatinine but no need for dialysis; Grade 3 > than twofold rise in serum creatinine and need for dialysis. There were 102 patients (44%) who were classified as Grade 0 and 81 patients (35%) who were classified as Grade 1 renal dysfunction. Severe renal dysfunction (Grades 2 and 3) was observed in 49 of the 232 patients (21%). This severe renal dysfunction of 21% compares with a previously reported 53% incidence of severe renal dysfunction for allogeneic bone marrow transplantation. Similarly, the frequency of hepatic VOD was less (4.7% or 11 of 232 patients) in this autologous bone marrow transplant study as compared to a reported incidence of hepatic VOD ranging from 22 to 53% in large series of allogeneic bone marrow transplant patients. The severe renal dysfunction (Grades 2 and 3) in the present autologous hematopoietic cell support study correlated most significantly with sepsis, liver and pulmonary dysfunction. The major fall in GFR occurred during chemotherapy but before hematopoietic cell support, thus primarily incriminating the cytoreductive therapy rather than the hematopoietic cell support. The only significant effect of different chemotherapy protocols was, at four weeks, the Taxol-treated group had a significantly lower creatinine clearance as compared to the BCNU treated group.

Use of amifostine in bone marrow purging

One of the main obstacles for the use of high-dose chemotherapy with autologous hematopoietic progenitor cell support in the treatment of malignancies is the possibility of reinfusing clonogenic tumor cells with the hematopoietic graft. Purging of the graft with chemicals can reduce the number of tumor cells but can also damage the normal hematopoietic progenitors. Preclinical studies showed that the phosphorylated sulfhydryl compound amifostine (WR-2721) can protect normal hematopoietic progenitors from damage from alkylating agents. We conducted a randomized clinical trial in patients with breast cancer, non-Hodgkin's lymphoma, and Hodgkin's disease undergoing autologous bone marrow transplant. In this study, patients were randomized to have their bone marrow purged with 4-hydroperoxycyclophosphamide (4-HC) with (arm A) or without (arm B) amifostine. The percentage of colony-forming unit granulocyte-macrophages recovered after purging was higher in the amifostine arm, both in patients with breast cancer and in those with lymphoma, although this difference was not statistically significant. In addition, the time to engraftment was significantly shorter in the amifostine arm in both cohorts. We showed that pretreatment of bone marrow with amifostine prior to purging with 4-HC can protect normal hematopoietic progenitors from damage by 4-HC. This resulted in shorter engraftment rates and less need for supportive care.

Species-, serogroup-, and serovar-specific epitopes are juxtaposed in variable sequence region 4 of the major outer membrane proteins of some Chlamydia trachomatis serovars

Synthetic peptides and murine monoclonal antibodies were used to map cross-reactive chlamydial epitopes. A species-specific epitope in the central region of variable sequence region 4 abuts the amino-terminal end of a B-serogroup-specific or F/G-serogroup-specific epitope, which in turn abuts known serovar-specific epitopes. The carboxyl-terminal portion of variable sequence region 4 (residues 297 to 314) comprises a region of end-to-end B-cell epitopes in some serovars of the B and F/G serogroups.

Air quality in an animal facility: particulates, ammonia, and volatile organic compounds

Concentrations of ammonia, volatile organic compounds, particles, and mouse allergen were measured in an animal facility. Ammonia concentrations averaged less than 1 ppm, below any health-based standards. The concentrations of volatile organic compounds were in the 5-15 micrograms/m3 range. Among the volatile organic compounds found, only the terpenes a-pinene and a-terpinol (which may be derived from the pine shavings used as bedding) were consistently present in concentrations greater than outdoor air. The primary air contaminant present at concentrations high enough to be of known physiological significance was the mouse allergen, Mus ml. To determine which activities in an animal room generated the highest concentrations of airborne Mus ml, a monitor that counted particles continuously was used. The particle counts were correlated with allergen levels in the worker's breathing zone (r50.83,p,0.05). Thus, a particle counter can be used effectively in an animal facility to identify specific activities that generate high levels of both particles and allergen. Such activities included changing mice from soiled to clean cages, cleaning floors, and changing foam inserts in pressurized individually ventilated cages. To reduce exposure to allergen during cage changing, which is the major activity for an animal caretaker, a capture-type ventilated changing table was designed and tested. Use of such a table reduced exposure to allergen in the worker's breathing zone from 4.961.1 to 2.160.3 ng Mus ml/m3, a level comparable to background levels.

High-dose paclitaxel, cyclophosphamide, and cisplatin with autologous hematopoietic progenitor-cell support: a phase I trial

PURPOSE

To determine the maximal-tolerated dose (MTD) of paclitaxel in combination with high-dose cyclophosphamide (CPA) and cisplatin (cDDP) followed by autologous hematopoietic progenitor-cell support (AHPCS).

PATIENTS AND METHODS

Forty-nine patients with poor-prognosis breast cancer, non-Hodgkin's lymphoma (NHL), or ovarian cancer were treated with escalating doses of paclitaxel infused over 24 hours, followed by CPA (5,625 mg/m2 intravenously over 1 hour in three divided doses) and cDDP (165 mg/m2 intravenously as a continuous infusion over 72 hours) and AHPCS. Pharmacokinetic measurements for each drug were performed.

RESULTS

Dose-limiting toxicities were encountered in two patients at 825 mg/m2 of paclitaxel; one patient died of multiorgan failure that involved the lung, CNS, and kidneys, and the other developed grade 3 respiratory, CNS, and renal toxicity, which resolved. The MTD of this combination was determined to be paclitaxel 775 mg/m2, CPA 5,625 mg/m2, and cDDP 165 mg/m2 followed by AHPCS. Sensory polyneuropathy and mucositis were prominent toxicities, but both were reversible and tolerable. The pharmacokinetics of paclitaxel correlated significantly with the severity of mucositis (P < .001) and peripheral neuropathy (P < .00004). Eighteen of 33 patients (54%) with measurable, heavily pretreated metastatic breast cancer achieved a partial response (PR). Responses were also observed in patients with NHL (four of five patients) and ovarian cancer (two of two).

CONCLUSION

It is possible to escalate the dose of paclitaxel to 775 mg/m2 in combination with 5,625 mg/m2 of CPA, 165 mg/m2 of cDDP, and AHPCS. An encouraging response rate in poor-prognosis patients with breast cancer, NHL, and ovarian cancer warrants further study.

Declining prevalence of chlamydial infection among adolescent girls

BACKGROUND AND OBJECTIVES

Chlamydial control programs that identify and treat infected persons have been used as a means of reducing prevalence and morbidity. The overall objective of the current study was to examine the prevalence of chlamydial infection during the course of such a program.

GOALS

To determine whether a reduction in isolation rates was evident among adolescent girls during the 8.75 years that the control program has been in place.

STUDY DESIGN

The study population consisted of all 4,329 sexually active girls between the ages of 13 and 19 attending the four adolescent health clinics in Indianapolis, Indiana, during the period beginning October 1, 1985, and ending June 30, 1994. All girls were cultured for Chlamydia trachomatis, and behavioral data were collected for those attending the clinics before 1989. The trend in quarterly isolation rates was examined using linear regression analysis.

RESULTS

Results showed that there was a significant decrease (P = 0.0001), from 25.9% to 9.7%, in the first-visit chlamydial isolation rate over the study period. Behavioral data showed decreases in the frequency of sexual intercourse and in lifetime years of sexual activity, as well as an increase in condom use.

CONCLUSIONS

The quarterly isolation rates showed that there has been a 63% decline in chlamydial infection among adolescent girls attending the clinics for the first time.

Threat-induced behavioural inhibition in Japanese quail genetically selected for contrasting adrenocortical response to mechanical restraint

1. Behavioural and adrenocortical responses to brief mechanical restraint were examined in 28-d-old female Japanese quail of two lines which had been genetically selected over several generations for either reduced (LS, low stress) or exaggerated (HS, high stress) plasma corticosterone response to brief immobilisation in a metal box. 2. As expected, quail of the LS line showed lower adrenocortical responses to restraint than did their HS line counterparts. The LS quail also struggled much sooner and more often during the 5 min restraint period than did the HS ones. Collectively, these and previously reported line differences in behavioural, catecholamine and adrenocortical responsiveness are consistent with an interpretation based on the adoption of active and passive coping strategies respectively by LS and HS quail upon their exposure to alarming stimuli.