Automating Electronic Health Record Data Quality Assessment

Information systems such as Electronic Health Record (EHR) systems are susceptible to data quality (DQ) issues. Given the growing importance of EHR data, there is an increasing demand for strategies and tools to help ensure that available data are fit for use. However, developing reliable data quality assessment (DQA) tools necessary for guiding and evaluating improvement efforts has remained a fundamental challenge. This review examines the state of research on operationalising EHR DQA, mainly automated tooling, and highlights necessary considerations for future implementations. We reviewed 1841 articles from PubMed, Web of Science, and Scopus published between 2011 and 2021. 23 DQA programs deployed in real-world settings to assess EHR data quality (n = 14), and a few experimental prototypes (n = 9), were identified. Many of these programs investigate completeness (n = 15) and value conformance (n = 12) quality dimensions and are backed by knowledge items gathered from domain experts (n = 9), literature reviews and existing DQ measurements (n = 3). A few DQA programs also explore the feasibility of using data-driven techniques to assess EHR data quality automatically. Overall, the automation of EHR DQA is gaining traction, but current efforts are fragmented and not backed by relevant theory. Existing programs also vary in scope, type of data supported, and how measurements are sourced. There is a need to standardise programs for assessing EHR data quality, as current evidence suggests their quality may be unknown.

Vat Photopolymerization of Reinforced Styrene-Butadiene Elastomers: A Degradable Scaffold Approach

Vat photopolymerization (VP) is a high-throughput additive manufacturing modality that also offers exceptional feature resolution and surface finish; however, the process is constrained by a limited selection of processable photocurable resins. Low resin viscosity (<10 Pa·s) is one of the most stringent process-induced constraints on resin processability, which in turn limits the mechanical performance of printed resin systems. Recently, the authors created a VP-processable photosensitive latex resin, where compartmentalization of the high molecular weight polymer chains into discrete particles resulted in the decoupling of viscosity from molecular weight. However, the monomers used to form the hydrogel green body resulted in decreased ultimate material properties due to the high cross-link density. Herein, we report a novel scaffold that allows for facile UV-based AM and simultaneously enhances the final part's material properties. This is achieved with a chemically labile acetal-containing cross-linker in conjunction with N-vinylpyrrolidone, which forms a glassy polymer after photocuring. Subsequent reactive extraction cleaves the cross-links and liberates the glassy polymer, which provides mechanical reinforcement of the geometrically complex VP-printed elastomer. With only a 0.1 wt % loading of photoinitiator, G'/G'' crossover times of less than 1 s and green body plateau moduli nearing 10⁵ Pa are obtained. In addition, removal of the hydrophilic and thermally labile scaffold results in decreased water uptake and increased thermal stability of the final printed part. Ultimate strain and stress values of over 650% and 8.5 MPa, respectively, are achieved, setting a new benchmark for styrene-butadiene VP elastomers.

Managing Pandemic Responses with Health Informatics - Challenges for Assessing Digital Health Technologies

Objectives : To highlight the role of technology assessment in the management of the COVID-19 pandemic.

Method : An overview of existing research and evaluation approaches along with expert perspectives drawn from the International Medical Informatics Association (IMIA) Working Group on Technology Assessment and Quality Development in Health Informatics and the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems.

Results : Evaluation of digital health technologies for COVID-19 should be based on their technical maturity as well as the scale of implementation. For mature technologies like telehealth whose efficacy has been previously demonstrated, pragmatic, rapid evaluation using the complex systems paradigm which accounts for multiple sociotechnical factors, might be more suitable to examine their effectiveness and emerging safety concerns in new settings. New technologies, particularly those intended for use on a large scale such as digital contract tracing, will require assessment of their usability as well as performance prior to deployment, after which evaluation should shift to using a complex systems paradigm to examine the value of information provided. The success of a digital health technology is dependent on the value of information it provides relative to the sociotechnical context of the setting where it is implemented.

Conclusion : Commitment to evaluation using the evidence-based medicine and complex systems paradigms will be critical to ensuring safe and effective use of digital health technologies for COVID-19 and future pandemics. There is an inherent tension between evaluation and the imperative to urgently deploy solutions that needs to be negotiated.

3D Printing Latex: A Route to Complex Geometries of High Molecular Weight Polymers

Vat photopolymerization (VP) additive manufacturing fabricates intricate geometries with excellent resolution; however, high molecular weight polymers are not amenable to VP due to concomitant high solution and melt viscosities. Thus, a challenging paradox arises between printability and mechanical performance. This report describes concurrent photopolymer and VP system design to navigate this paradox with the unprecedented use of polymeric colloids (latexes) that effectively decouple the dependency of viscosity on molecular weight. Photocrosslinking of a continuous-phase scaffold, which surrounds the latex particles, combined with in situ computer-vision print parameter optimization, which compensates for light scattering, enables high-resolution VP of high molecular weight polymer latexes as particle-embedded green bodies. Thermal post-processing promotes coalescence of the dispersed particles throughout the scaffold, forming a semi-interpenetrating polymer network without loss in part resolution. Printing a styrene-butadiene rubber latex, a previously inaccessible elastomer composition for VP, exemplified this approach and yielded printed elastomers with precise geometry and tensile extensibilities exceeding 500%.

Mixed methods protocol for a realist evaluation of electronic personal health records design features and use to support medication adherence (ePHRma)

BACKGROUND

National Health Service policy suggests that increasing usage of electronic personal health records (PHR) by patients will result in cost savings and improved public health. Medication adherence means that patients take their prescribed medication as agreed with their doctors. Some of the claimed benefits of PHRs are decreasing healthcare costs and improving medication adherence and patient outcomes.

METHODS

This is a mixed methods convergent study, primarily qualitative. The qualitative and quantitative data collection and analysis will occur in parallel, and then be synthesised. We are interviewing and surveying adults with long-term conditions to identify what are the most important and useful features of their current PHR. The data collection comprises patient demographics, the Medication Adherence Questionnaire, the personality scale Big Five Inventory-2 Extra-Short Form and the WHO Quality of Life-BREF scale. Qualitative data will be analysed using the Framework method.

ETHICS

We have received a favourable ethical opinion from the Health Research Authority/Research Ethics Committee.

Light and latex: advances in the photochemistry of polymer colloids

Unparalleled temporal and spatial control of colloidal chemical processes introduces immense potential for the manufacturing, modification, and manipulation of latex particles.

A review of measurement practice in studies of clinical decision support systems 1998-2017

OBJECTIVE

To assess measurement practice in clinical decision support evaluation studies.

MATERIALS AND METHODS

We identified empirical studies evaluating clinical decision support systems published from 1998 to 2017. We reviewed titles, abstracts, and full paper contents for evidence of attention to measurement validity, reliability, or reuse. We used Friedman and Wyatt's typology to categorize the studies.

RESULTS

There were 391 studies that met the inclusion criteria. Study types in this cohort were primarily field user effect studies (n = 210) or problem impact studies (n = 150). Of those, 280 studies (72%) had no evidence of attention to measurement methodology, and 111 (28%) had some evidence with 33 (8%) offering validity evidence; 45 (12%) offering reliability evidence; and 61 (16%) reporting measurement artefact reuse.

DISCUSSION

Only 5 studies offered validity assessment within the study. Valid measures were predominantly observed in problem impact studies with the majority of measures being clinical or patient reported outcomes with validity measured elsewhere.

CONCLUSION

Measurement methodology is frequently ignored in empirical studies of clinical decision support systems and particularly so in field user effect studies. Authors may in fact be attending to measurement considerations and not reporting this or employing methods of unknown validity and reliability in their studies. In the latter case, reported study results may be biased and effect sizes misleading. We argue that replication studies to strengthen the evidence base require greater attention to measurement practice in health informatics research.

Reflecting and Looking to the Future: What Is the Research Agenda for Theory in Health Informatics?

In this chapter, we reflect on the aim and objectives of the textbook and address known gaps in our theory coverage. We reinforce the importance of theory in health informatics and review the varying disciplinary origins of the theories considered in the book. We discuss the question of what makes a good theory and how to know which one is relevant for a given study. We recognize the limitations of the body of theory that we have presented and suggest what might be regarded as "native" theory that is original to health informatics. Finally, we propose topics to form a research agenda for theory in health informatics.

Artificial Intelligence in Clinical Decision Support: Challenges for Evaluating AI and Practical Implications

OBJECTIVES

This paper draws attention to: i) key considerations for evaluating artificial intelligence (AI) enabled clinical decision support; and ii) challenges and practical implications of AI design, development, selection, use, and ongoing surveillance.

METHOD

A narrative review of existing research and evaluation approaches along with expert perspectives drawn from the International Medical Informatics Association (IMIA) Working Group on Technology Assessment and Quality Development in Health Informatics and the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems.

RESULTS

There is a rich history and tradition of evaluating AI in healthcare. While evaluators can learn from past efforts, and build on best practice evaluation frameworks and methodologies, questions remain about how to evaluate the safety and effectiveness of AI that dynamically harness vast amounts of genomic, biomarker, phenotype, electronic record, and care delivery data from across health systems. This paper first provides a historical perspective about the evaluation of AI in healthcare. It then examines key challenges of evaluating AI-enabled clinical decision support during design, development, selection, use, and ongoing surveillance. Practical aspects of evaluating AI in healthcare, including approaches to evaluation and indicators to monitor AI are also discussed.

CONCLUSION

Commitment to rigorous initial and ongoing evaluation will be critical to ensuring the safe and effective integration of AI in complex sociotechnical settings. Specific enhancements that are required for the new generation of AI-enabled clinical decision support will emerge through practical application.

The Safe and Effective Use of Shared Data Underpinned by Stakeholder Engagement and Evaluation Practice

Objectives:  The paper draws attention to: i) key considerations involving the confidentiality, privacy, and security of shared data; and ii) the requirements needed to build collaborative arrangements encompassing all stakeholders with the goal of ensuring safe, secure, and quality use of shared data.

Method:  A narrative review of existing research and policy approaches along with expert perspectives drawn from the International Medical Informatics Association (IMIA) Working Group on Technology Assessment and Quality Development in Health Care and the European Federation for Medical Informatics (EFMI) Working Group for Assessment of Health Information Systems.

Results:  The technological ability to merge, link, re-use, and exchange data has outpaced the establishment of policies, procedures, and processes to monitor the ethics and legality of shared use of data. Questions remain about how to guarantee the security of shared data, and how to establish and maintain public trust across large-scale shared data enterprises. This paper identifies the importance of data governance frameworks (incorporating engagement with all stakeholders) to underpin the management of the ethics and legality of shared data use. The paper also provides some key considerations for the establishment of national approaches and measures to monitor compliance with best practice.

Conclusion:  Data sharing endeavours can help to underpin new collaborative models of health care which provide shared information, engagement, and accountability amongst all stakeholders. We believe that commitment to rigorous evaluation and stakeholder engagement will be critical to delivering health data benefits and the establishment of collaborative models of health care into the future.

Learning health systems need to bridge the ‘two cultures’ of clinical informatics and data science

Background

UK health research policy and plans for population health management are predicated upon transformative knowledge discovery from operational ‘Big Data’. Learning health systems require not only data, but feedback loops of knowledge into changed practice. This depends on knowledge management and application, which in turn depends upon effective system design and implementation. Biomedical informatics is the interdisciplinary field at the intersection of health science, social science and information science and technology that spans this entire scope.

Issues

In the UK, the separate worlds of health data science (bioinformatics, ‘Big Data’) and effective healthcare system design and implementation (clinical informatics, ‘Digital Health’) have operated as ‘two cultures’. Much National Health Service and social care data is of very poor quality. Substantial research funding is wasted on ‘data cleansing’ or by producing very weak evidence. There is not yet a sufficiently powerful professional community or evidence base of best practice to influence the practitioner community or the digital health industry.

Recommendation

The UK needs increased clinical informatics research and education capacity and capability at much greater scale and ambition to be able to meet policy expectations, address the fundamental gaps in the discipline’s evidence base and mitigate the absence of regulation. Independent evaluation of digital health interventions should be the norm, not the exception.

Conclusions

Policy makers and research funders need to acknowledge the existing gap between the ‘two cultures’ and recognise that the full social and economic benefits of digital health and data science can only be realised by accepting the interdisciplinary nature of biomedical informatics and supporting a significant expansion of clinical informatics capacity and capability.

Measurement and Prediction of Progress in Delayed Wound Healing

Thirty chronic leg ulcers have been studied under controlled conditions until complete healing occurred. Measurement was performed weekly using a computer-linked stereocamera which is capable of measuring skin defects noninvasively with errors of less than 2%. There was a significant difference in healing rate for the first two weeks between clean ulcers entering the trial directly and ulcers admitted first for cleansing before joining the trial. The difference suggests that the weekly healing rate of an ulcer may take up to 2 weeks to respond to a new form of treatment. Absolute ulcer size, change in ulcer size and rate of epithelial migration did not correlate well with time to complete healing, but percentage change in area in the third week was found to be the parameter which gave the earliest close correlation with time to complete healing. Using this parameter, on the data available it was found that time to complete healing could be predicted to within one week for 50% of the ulcers, making this a simple and useful early predictor of treatment efficiency.

Genesis of a UK Faculty of Clinical Informatics at a time of anticipation for some, and ruby, golden and diamond celebrations for others

This Editorial marks the launch of the UK Faculty of Clinical Informatics (FCI) at the time when non-clinically qualified informaticiance are anticipating the lauch of  the Federation of Informatics Professionals in Health and Care (Fed-IP).      

Team Competencies and Educational Threshold Concepts for Clinical Information Modelling

Healthcare interoperability depends upon sound semantic models to support safe and reliable exchange of information. We argue that clinical information modelling requires a collaborative team of healthcare professionals, process and content analysts and terminologists and that 'separation of concerns' is unhelpful. We present six fundamental concepts that participants must understand to collaborate meaningfully in technology-agnostic information modelling.

Informatics for Health 2017: Advancing both science and practice

INTRODUCTION

The Informatics for Health congress, 24-26 April 2017, in Manchester, UK, brought together the Medical Informatics Europe (MIE) conference and the Farr Institute International Conference. This special issue of the Journal of Innovation in Health Informatics contains 113 presentation abstracts and 149 poster abstracts from the congress.

DISCUSSION

The twin programmes of "Big Data" and "Digital Health" are not always joined up by coherent policy and investment priorities. Substantial global investment in health IT and data science has led to sound progress but highly variable outcomes. Society needs an approach that brings together the science and the practice of health informatics. The goal is multi-level Learning Health Systems that consume and intelligently act upon both patient data and organizational intervention outcomes.

CONCLUSION

Informatics for Health demonstrated the art of the possible, seen in the breadth and depth of our contributions. We call upon policy makers, research funders and programme leaders to learn from this joined-up approach.

Measuring the operational impact of digitized hospital records: a mixed methods study

Background

Digitized (scanned) medical records have been seen as a means for hospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity.

Methods

Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which pre-defined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized.

Results

Four hundred six consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p = 0.016) and a significant difference in consultation times between specialties within hospitals (p = 0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p = 0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p > =0.285) or specialty level (p > =0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (p < =0.010, Δ = 01:50–07:10) and one specialty had a corresponding reduction in time spent searching paper records (p = 0.015, Δ = −00:28). Site B showed a notable increase in direct patient care (p < 0.001, Δ = 04:20–06:00) and time spent searching computer records (p < =0.043, Δ = 00:10–01:40) and reductions in the other time categories.

The focus group confirmed that the most recent clinical letter was a vital document in the patient record, often containing most of the required information. Concerns were expressed about consistency of scanning practice, causing uncertainty about what could be relied upon to exist in the digitized record. Benefits of digitized records included: access from multiple locations, better prepared ward rounds, improved inpatient handovers and an improved timeline of patient events. Limitations of digitized records included: increased complexity of creating a patient summary, display of specialised content such as hand-drawn diagrams, inability to quickly flick through the pages to find relevant content.

Conclusions

Digitized medical records can be implemented without detrimental operational impact. Inherent differences between specialties can outweigh the differences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

Mixed Methods: A Paradigm for Holistic Evaluation of Health IT

This contribution offers an overview of the 'third research paradigm', its historical roots and its relevance for health informatics. Using illustrative studies, we explore the concepts of triangulation and integration of quantitative and qualitative data and refute common philosophical objections to mixing different types of knowledge. We consider how the mixed method paradigm relates to two programme design and evaluation frameworks that are important for health informatics: realist evaluation and Theory of Change. We discuss how to manage practical challenges to this approach and explain how mixed method studies support an evidence-based approach to real world policy, planning and investment decisions.

Theoretical Foundations for Evidence-Based Health Informatics: Why? How?

A scientific approach to health informatics requires sound theoretical foundations. Health informatics implementation would be more effective if evidence-based and guided by theories about what is likely to work in what circumstances. We report on a Medinfo 2015 workshop on this topic jointly organized by the EFMI Working Group on Assessment of Health Information Systems and the IMIA Working Group on Technology Assessment and Quality Development. We discuss the findings of the workshop and propose an approach to consolidate empirical knowledge into testable middle-range theories.

A framework for promoting scholarship productivity in occupational therapy curricula

This paper describes a curricular model to support the production of quality research and development of occupational therapy professional students, prepared to become leaders in the production and utilization of evidence for practice. This model is designed for programs with faculty challenged by the dual mandate of program excellence and expectations for scholarly productivity needed for tenure and promotion: typically programs at research universities. The essence of the model is the paralleling of research and competencies for clinical practice where faculty and students participate as a community of scholars. It is based on the literature that addresses the tensions between achieving excellence in research and scholarly productivity, and excellence in teaching. The experience of one university with this model over a five-year period of time is shared with the student-faculty productivity outcomes. These outcomes include dissemination of 55 collaborative peer reviewed products and faculty has generated support for 25 paid graduate assistantships. The combination of student outcomes and faculty support for their research has strengthened the ability of the faculty to excel in meeting the University mandate of scholarship while providing a high quality professional educational program.

A collaborative teaching strategy for enhancing learning of evidence-based clinical decision-making

The educational literature cites a lack of student motivation to learn how to use research evidence in clinical decision-making because the students do not observe clinicians using evidence. This lack of motivation presents a challenge to educators as they seek to instill the value of evidence-based clinical decision-making (EBCD) in students. One problem is that students in entry-level programs do not have the experience needed to know what to look for, and secondly, clinical decision-making is contextually based in a patient problem. Our approach offers one solution to bridging the gap between classroom teaching and real-world implementation of EBCD through a three-phase collaborative approach. Occupational and physical therapy students are partnered with clinicians to find and appraise evidence to answer the real-world questions posed by these therapists. This paper describes the implementation of the partnership, teaching/learning outcomes, logistics, and implications for clinicians. We found this approach increased student motivation and greatly enhanced the learning experience. Future directions include implementing a framework which allows for the assessment of the strategy on the facility and creates opportunities to integrate the use of EBCD in all aspects of facility practice.

STAT-HI: A socio-technical assessment tool for health informatics implementations

This paper proposes a socio-technical assessment tool (STAT-HI) for health informatics implementations. We explore why even projects allegedly using sound methodologies repeatedly fail to give adequate attention to socio-technical issues, and we present an initial draft of a structured assessment tool for health informatics implementation that encapsulates socio-technical good practice. Further work is proposed to enrich and validate the proposed instrument. This proposal was presented for discussion at a meeting of the UK Faculty of Health Informatics in December 2009.

ST elevation on the exercise ECG in patients presenting with chest pain and no prior history of myocardial infarction

OBJECTIVE

To assess the aetiology, and prognosis of ST-segment elevation (STE) on the exercise electrocardiogram in patients with chest pain without a prior history of myocardial infarction (MI).

METHODS

Between January 1998 and December 2005, 14 941 exercise stress tests were performed to assess chest pain in patients without a prior history of MI. Those who developed STE were identified.

RESULTS

STE occurred in 0.78% (116/14 941). Coronary angiography was performed in 108 patients. All patients had at least one severe coronary artery stenosis (>70%). The site of STE on exercise ECG was shown to be 95.4% predictive of a severe stenosis in the coronary artery supplying that area. Lateral STE was rare (1/116). Ninety-eight patients underwent revascularisation; 67 patients had percutaneous coronary intervention (PCI) and 31 underwent coronary artery bypass grafting (CABG). Follow-up included recording of death, MI, cerebrovascular event, heart failure and target vessel revascularisation. The projected 7-year event-free survival probability was 62.1% for those undergoing CABG, 77.1% for those who had PCI and 68.6% for those not undergoing revascularisation (no difference between these three groups, log rank p = 0.802).

CONCLUSIONS

STE on the exercise ECG is rare but specific for ischaemic heart disease and is predictive of a severe stenosis in the corresponding coronary artery. Prognosis is favourable following revascularisation.

Developing a theoretical model of clinician information usage propensity

Based on qualitative research, we developed the theoretical construct "clinician information usage propensity" as a hypothetical indicator of attitudes and behaviour towards clinical information and systems. We devised a survey to validate the construct and had 146 responses. Principal components analysis extracted four factors accounting for 47.2% of the variance: beliefs about clinical judgement, beliefs about information quality, cultural resistance and cognitive approach. The components were reasonably consistent with the model but two factors (beliefs about information quality, cognitive approach) had low reliability (alpha<0.6). Cultural resistance was the main factor and correlated with gender, grade and age group. Female clinicians showed significantly higher cultural resistance and preference for narrative; hospital doctors generally had higher cultural resistance than general practitioners. As only 47.2% of the variance was explained, further work is needed to refine the instrument to remove redundancy, improve sensitivity on the identified components and allow the construct to be explored as a form of technology adoption model. We posit that beliefs about clinical judgement merit further attention in medical informatics research.

Outcome after radial forearm, gastro-omental, and jejunal free flaps in oral and oropharyngeal reconstruction

We undertook a retrospective study of the outcome of radial forearm, gastro-omental, and jejunal free tissue transfer for oral and oropharyngeal reconstruction in 30 patients (10 in each group). No significant differences were found between the type of free flap and the clinical outcome. More long-term difficulties were experienced with swallowing than with speech. The selection of free flap did not correlate with speech function (P=0.44), swallowing (P=0.68), or management of saliva (P=0.59). No significant difference was found between the patients' outcome and the site of resection of the tumour. There were more complications after gastro-omental flaps and this may influence the choice of reconstruction.

Clinically integrated studies in pathology: their contribution to atherosclerosis research

This article, prepared in honor of Daria Haust, reviews some features of research into atherosclerosis and coronary heart disease over the past 150 years, and beyond. Attention is drawn to problems arising when people of strong personality dominate a particular field of research to the exclusion of pertinent observations that do not fit neatly into their particular paradigm. As the world becomes more complex and, in theory at least, communications between scientists become easier, these dangers are not necessarily diminished. Clinical medicine in its broadest sense must continue to relate in the traditional way to the specialties grouped within pathology. Undergraduates must receive instruction concerning the importance of the historical record and an understanding of the nature of science, its strengths, limitations, and boundaries.

Does the "Thunderbirds syndrome" still exist

Rationing of resources within both the private and public health care systems is a fact of life. The Thunderbirds TV series encapsulated an idealistic philosophy that life should be saved independent of the pecuniary cost. Doctors, in particular, are trapped between their role as advocates for the patient within the "Thunderbirds" philosophy and as citizens with a responsibility to use resources wisely. This dichotomy is challenged by point of care rationing, which can conflict with clinical responsibilities, undermines the patient-doctor relationship and is often undertaken in a clandestine manner. This form of controlling health costs is difficult to justify from an ethical perspective, particularly when other forms of health care rationing and expenditure are frequently modulated by political expediency and inadequate economic modelling. Indeed, focusing on improving quality and disease prevention, rather than reducing marginal costs can often control the long-term growth in health expenditure. Doctors have a responsibility to ensure that rationing decisions are made but these should be made as part of a transparent, evidence-based and democratic process away from the point of care. While the resources to implement the "Thunderbirds Syndrome" have never been available, the philosophy must remain at the heart of patient-doctor relationship.

Consensus viewpoint on the treatment of postmenopausal osteoporosis. The Ad Hoc Group on Osteoporosis

Treatment for postmenopausal osteoporosis should be offered to those with a history of fractures following minimal trauma or with a bone density significantly below the range seen in young normal adults. Underlying diseases contributing to the reduced bone density should be sought and treated appropriately. Lifestyle issues such as smoking, alcohol intake and exercise should be addressed. A calcium intake of at least 1.5 g/day should be achieved. Hormone replacement therapy is the first line pharmacological intervention. The bisphosphonates provide a satisfactory alternative for those unable or unwilling to take hormone replacement therapy.

Effects of catecholamines on isolated human colonic smooth muscle

1. The effects of catecholamines and some adrenoceptor agonists and antagonists on isolated preparations of human colonic smooth muscle obtained from surgical resections were examined. 2. Strips of circular smooth muscle displayed rhythmic myogenic spontaneous contractions which were inhibited by catecholamines with an order of potency of isoprenaline (1.0) > noradrenaline (0.32) > adrenaline (0.2). Phentolamine (0.7 microM) significantly shifted the noradrenaline concentration-response curve (CRC) to the right but had no significant effect on isoprenaline or adrenaline. Propranolol (1 microM) significantly shifted the isoprenaline to the right but had no significant effect on noradrenaline or adrenaline. 3. Salbutamol (30 microM) had no inhibitory effect on the spontaneous activity and ICI 118,551 (1 microM) had no effect on inhibitory responses to isoprenaline. Betaxolol (1 microM) significantly shifted the CRC to isoprenaline to the right. BRL 37344 had no effect on spontaneous activity. 4. Responsiveness of circular strips to catecholamines was not affected by age of the patient and no consistent differences between males and females were shown. 5. Strips of taenia coli exhibited little or no spontaneous phasic activity. Noradrenaline and isoprenaline relaxed KCl-induced tone. The effects of noradrenaline and isoprenaline were antagonized by propranolol but not by phentolamine. BRL 37344 had no effect on KCl-induced tone. 6. In conclusion, catecholamines relaxed spontaneous activity of human colon circular smooth muscle through an action on both alpha- and beta-adrenoceptors. The alpha-adrenoceptors were of the alpha 1-subtype. The beta-adrenoceptor-mediated relaxation appeared to be primarily beta 1. In taenia coli, catecholamines relaxed KCl-induced tone via beta-adrenoceptors only.

Adhesion receptor phenotypes of murine lung CD4+ T cells during the pulmonary immune response to sheep erythrocytes

Understanding the molecular mechanisms of pulmonary lymphocyte recruitment is a crucial step toward selective control of immune lung diseases and infections in immunocompromised hosts. To dissect these mechanisms, we are studying the response induced in primed C57BL/6 mice by intratracheal challenge with the T cell-dependent antigen, sheep red blood cells (SRBC). This study used four-parameter flow cytometry to examine expression by CD4+ murine T cells in peripheral blood and lungs of receptors known to be differentially expressed on primed human lymphocytes (CD2, CD11a, CD44, CD45RB, CD49d, and L-selectin). Compared with peripheral blood, more lung CD4+ T cells recovered by bronchoalveolar lavage (BAL) showed a primed phenotype. Judged by low expression of CD45RB or L-selectin, 76 to 90% of BAL CD4+ T cells were primed at all times. Adhesion receptor phenotype of CD4+ T cells in BAL and lung interstitium agreed closely, although BAL contained a greater percentage of primed cells. The percentage of CD4+ T cells with high expression of CD44+ and CD49d increased late in the response. However, when considering only upregulated adhesion receptors which might mediate recruitment, 22 to 52% of CD4+ T cells in BAL did not have increased adhesion receptor expression. Longer duration between priming and challenge did not increase adhesion receptor upregulation. High adhesion receptor expression was least evident during the periods of maximal lymphocyte influx, suggesting that factors other than increased surface density of organ-nonspecific adhesion receptors contribute to lymphocyte recruitment during pulmonary immune responses.

No evidence for a general change in contractile responsiveness of the mesenteric artery with aging

Rings of human mesenteric artery (1-3 mm diameter) suspended in Krebs solution were contracted (maximal contraction relative to KCl 80 mM = 100%) by the thromboxane mimetic U46619 (190 +/- 10%), noradrenaline (162 +/- 9%), angiotensin II (107 +/- 11%), and 5-hydroxytryptamine (5-HT) (96 +/- 10%). Reducing extracellular Ca2+ strongly inhibited the maximal contraction to angiotensin II and 5-HT and moderately inhibited the maximal contraction to noradrenaline, but had less effect on the maximal contraction to U46619 (contraction in Ca2+ 1.3 microM was reduced to 24 +/- 5, 20 +/- 3, 38 +/- 4 and 52 +/- 4% respectively of the contraction in 2.5 mM Ca2+). Reducing extracellular Ca2+ lowered sensitivity to 5HT, angiotensin II, and U46619, but did not alter sensitivity to noradrenaline. The EC50 and maximal contraction for each of the 4 agonists did not change with patient age at 2.5 mM Ca2+ or in reduced extracellular Ca2+. It is concluded that aging does not affect the responsiveness of mesenteric arterial smooth muscle to physiological vasoconstrictors.

Helicobacter pylori and chronic antral gastritis in elderly patients

Fifty-five elderly patients with chronic antral gastritis (CAG) were studied to assess the relationship between Helicobacter pylori (H. pylori) status and CAG subtypes as specified in the Sydney System for Gastritis Classification. Twenty-eight patients (51%) were H. pylori positive and 27 (49%) H. pylori negative. H. pylori-positive patients had a significantly greater association with features of severe active CAG (chronic inflammation and polymorph activity) than H. pylori-negative patients. No association was apparent between H. pylori and more advanced stages of CAG (atrophy and intestinal metaplasia) thought to carry pre-malignant potential. The recognized association between dyspeptic symptoms in elderly people and an H. pylori-positive gastritis was confirmed. Use of NSAIDs correlated with a predominantly H. pylori-negative gastritis which was relatively asymptomatic.

Experimental murine pulmonary cryptococcosis. Differences in pulmonary inflammation and lymphocyte recruitment induced by two encapsulated strains of Cryptococcus neoformans

BACKGROUND

Cryptococcus neoformans, the most common cause of lethal mycosis in AIDS, usually causes only subclinical pneumonitis in normal hosts. However, cryptococcosis can induce various pulmonary inflammatory reactions, and pulmonary cellular immunity is postulated to prevent dissemination. We hypothesized that cryptococcal strains possess different capacities to induce recruitment to the lungs of inflammatory cells, especially lymphocytes, which are necessary for cryptococcal clearance.

EXPERIMENTAL DESIGN

We examined the pulmonary response of CBA/J mice to intratracheal inoculation with C. neoformans of either of two strains: 52D (ATCC 24067), which rarely kills immunocompetent mice; and 145A (ATCC 62070), which is uniformly fatal. From 2-42 days after inoculation, lungs were either examined grossly and microscopically or were enzymatically digested and inflammatory cells counted and analyzed by flow cytometry. At 42 days, organism burden in lung and brain was quantified by colony-forming unit assay.

RESULTS

Pulmonary inflammation differed greatly between the two strains. Strain 52D induced dense perivascular and alveolar inflammation; infection progressed to day 21 and then waned. In contrast, strain 145A induced delayed, meager lymphocytic infiltration and slight alveolitis; organisms grew progressively. Recovery of inflammatory cells increased by day 13 with strain 52D, but not until day 31 with strain 145A. Although all lymphocyte subsets were greater in 52D infection, the disparity was greatest for CD4+ T cells. Nevertheless, lymphocytes from paratracheal nodes of infected mice proliferated in vitro to heat-killed cryptococci, indicating immune recognition of both strains. At day 42, strain 52D lightly infected lungs but not brain, whereas strain 145A heavily infected lungs and brain. CONCLUSIONS; Cryptococcal strains differ in their capacity to induce pulmonary cellular inflammation, especially CD4+ T cell recruitment. Our results suggest that strain-specific difference in the organism's ability to induce (or evade) pulmonary inflammation contributes to the outcome of infection.

Imaging of pulmonary vascular disease by intravascular ultrasound

To assess the ability of intravascular ultrasound (IVUS) to image changes in the pulmonary arterial wall associated with pulmonary hypertension (PHT), 10 subjects requiring diagnostic right and left heart catheterization were studied. In addition to measurements of pulmonary artery pressure and pulmonary vascular resistance and pulmonary angiography, when indicated, all underwent simultaneous IVUS imaging in the pulmonary arterial system using a 20 MHz ultrasound transducer mounted on a 2 mm diameter catheter. Four patients had normal pulmonary artery pressures and 6 had varying degrees of PHT. Satisfactory ultrasound images were obtained in 9 out of the 10 patients. In those with normal pulmonary artery pressures ultrasound showed a thin vessel wall with no distinction between separate layers. In patients with systemic PHT, a three-layered vessel wall was apparent and areas compatible with intimal proliferation were seen. In a patient with pulmonary embolic disease areas consistent with mural thrombus were detected at sites of luminal narrowing on the pulmonary angiogram. IVUS is capable of imaging some of the morphological changes in the wall of the pulmonary artery known to occur in longstanding PHT and may therefore become a useful adjunct to haemodynamic measurements and pulmonary angiography for the in vivo assessment of pulmonary vascular disease.

Vasodilator action of cromakalim on human mesenteric artery

Human mesenteric artery rings (1-3 mm diameter obtained from bowel resections), precontracted with KCl 80 mM, were relaxed by cromakalim (IC50 = 0.39 +/- 0.04 microM, maximum inhibition 69 +/- 2%). Cromakalim was more effective at inhibiting KCl 40 mM than KCl 80 mM. Cromakalim also inhibited contraction produced by noradrenaline, and was a more potent inhibitor of the second phase of the noradrenaline contraction than of the first phase.

Apical hypertrophic cardiomyopathy presenting as acute subendocardial myocardial infarction

Two patients with apical hypertrophic cardiomyopathy presented with angina at rest and giant inverted T waves in precordial leads on the electrocardiogram. At cardiac catheterisation one patient had mild coronary artery disease, the other had normal coronary arteries. In both, there was a systolic pressure gradient between the apex and main left ventricular cavity exceeding 100 mmHg. The presence of rest angina with the electrocardiographic findings lead to a mistaken, initial diagnosis of acute subendocardial myocardial infarction.

Bovine internal mammary artery as a conduit for coronary revascularization: long-term results

Graft patency after coronary artery bypass grafting depends largely on the choice of conduit. Because an increasing number of patients have insufficient or poor-quality autologous material, there is a need for a suitable synthetic graft that is readily available and easy to handle and that has good long-term patency. Early results suggest that the bovine internal mammary artery graft may meet these criteria. We have used a total of 26 such grafts in 18 patients. Postoperative angiography has been performed in 19 grafts in 14 patients, 3 to 23 months after operation; of these grafts, 3 are currently patent (15.8%, compared with 85.7% and 75.0% patency for native internal mammary artery and saphenous vein grafts in the same patients). We report the results of clotting studies and an analysis of lipid status. These patients do not, however, appear to represent any atypical group, either in terms of coagulopathy, native coronary artery size, or the type of vessel disease. Nevertheless, our poor results contrast markedly with the early enthusiasm reported from other centers.

Principal alterations to drug kinetics and dynamics in the elderly

People over the age of 64 constitute 15% of the population in the UK, yet they consume approximately 30% of all National Health Service drug prescriptions, and adverse drug reactions account for 10.4% of all admissions to geriatric medical assessment wards. Many published studies concerning the pharmacology of old age are seriously flawed. Problems include failure to measure the drug bio-availability and the selection of subjects with overt or sub-clinical disease. It is difficult to make general rules about the effect of ageing on drug kinetics and dynamics. Each drug has to be tested separately.

Transoesophageal echocardiography in neonates, infants and children: applicability and diagnostic value in everyday practice of a cardiothoracic unit

OBJECTIVE

To determine the applicability of and information obtained by transoesophageal echocardiography in neonates, infants, and children in every day practice of a cardiothoracic unit.

DESIGN

Four month prospective study.

SETTING

Supraregional centre for paediatric cardiothoracic services.

PATIENTS AND METHODS

58 patients aged between four days and 16 years with a wide range of cardiovascular disease underwent transoesophageal echocardiography under sedation or general anaesthetic. One of two paediatric probes (6 or 7 mm diameter), or an adult probe (13 mm in diameter) was used. Whenever possible the investigation was immediately preceded by precordial echocardiography.

MAIN OUTCOME MEASURES

Success, failure, technical difficulties, and complications of probe introduction and, when possible, comparison of the information obtained with that obtained from precordial echocardiography.

RESULTS

Introduction of the probe was successful in 57 of the 58 patients. The only complication encountered was transient bradycardia during manipulation of the probe in a 2.2 kg baby. The adult (13 mm) probe was successfully used in children as small as 7.0 kg. Below this weight a smaller paediatric probe was required. In 56% of cases transoesophageal ultrasound provided information not obtained from the precordial approach. The technique was of particular value perioperatively and in the immediate postoperative period in neonates and infants and in the presence of valve prostheses and the investigation of mediastinal tumours in older children.

CONCLUSIONS

Transoesophageal echocardiography is a valuable additional investigative tool for children of all ages. It is of particular value when acquisition of precordial image is impaired around the time of and after operation and in children with prosthetic valves or mediastinal tumour. Image quality was superior with the adult probe and we recommend the use of this probe unless the patient's weight is below 7 kg, when a paediatric probe allows this technique to be used usefully and safely in babies as small as 2.2 kg.

Age-associated changes in mesenteric arteries

Vascular disease increases in incidence with age and is the commonest cause of morbidity and mortality among elderly people. Hypertension is associated with hypertrophy of the arterial media. This study was designed to investigate changes in arterial structure that may occur with age independent of blood pressure. Collapsed sections of human mesenteric arteries (external diameter 2-3 mm) were measured using a semi-automatic image analysis system. There was a nonlinear increase in both the wall/lumen area ratio and the relative intimal area with age. There were no significant relationships between blood pressure and either the wall/lumen ratio or the relative intimal area.