Reengineering health care materials management

Health care executives across the country, faced with intense competition, are being forced to consider drastic cost cutting measures as a matter of survival. The entire health care industry is under siege from boards of directors, management and others who encourage health care systems to take actions ranging from strategic acquisitions and mergers to simple "downsizing" or "rightsizing," to improve their perceived competitive positions in terms of costs, revenues and market share. In some cases, management is poorly prepared to work within this new competitive paradigm and turns to consultants who promise that following their methodologies can result in competitive advantage. One favored methodology is reengineering. Frequently, cost cutting attention is focused on the materials management budget because it is relatively large and is viewed as being comprised mostly of controllable expenses. Also, materials management is seldom considered a core competency for the health care system and the organization performing these activities does not occupy a strongly defensible position. This paper focuses on the application of a reengineering methodology to healthcare materials management.     

What is the best method of surgical training?: A report of America's leading senior surgeons

OBJECTIVES: To characterize the career choices and developments made by leading senior surgeons in this country and to examine hypothetically whether application of a short tracking program would have hindered their career decisions. DESIGN: A survey pertaining to each surgeon's career, decisions, and opinions concerning surgical training. SETTING AND PARTICIPANTS: Senior surgeons of regional and national surgical societies. MAIN OUTCOME MEASURE: Survey responses. RESULTS: A total of 352 surveys (41.4%) were received. Respondents answered that the most common reasons for choosing a specialty were role models or mentors (56%), research (51%), and available patient population (23%). The 2 most common stages in a career at which the respondents became interested in a specialty, or an area of expertise, were at the junior residency level (when the specialty was chosen) and at the assistant professor level (when a more specific topic within the specialty was chosen). The most common stage at which the group believed they acquired their expertise was also at the assistant professor level. Seventy-one percent of respondents believed broad training was superior to a short tracking system, although none had participated in shortened surgical training. CONCLUSIONS: Most leading senior surgeons in this country still believe that broad surgical training is superior and should be maintained. Because career specialties in this surveyed group were generally chosen in early residency, a hypothetical application of the short tracking system would have still allowed for these important decisions to be made. Also, it seems likely that specialty and career development would not have been hindered because "expertization" mostly occurred after training was completed. Regardless of training method, a role model or mentor seems most important in career choices and developments.     

Human immunodeficiency virus infection, Part II

The acceptance of highly active antiretroviral therapy (HAART) among patients and health care providers has had a dramatic impact on the epidemiology and clinical characteristics of many opportunistic infections associated with human immunodeficiency virus (HIV). Previously intractable opportunistic infections and syndromes are now far less common. In addition, effective antibiotic prophylactic therapies have had a profound impact on the risk of patients developing particular infections and on the incidence of these infections overall. Most notable among these are Pneumocystis carinii, disseminated Mycobacterium avium complex, tuberculosis, and toxoplasmosis. Nevertheless, infections continue to cause significant morbidity and mortality among patients who are infected with HIV. The role of HAART in many clinical situations is unquestioned. Compelling data from clinical trials support the use of these therapies during pregnancy to prevent perinatal transmission of HIV. HAART is also recommended for health care workers who have had a "significant" exposure to the blood of an HIV-infected patient. Both of these situations are discussed in detail in this article. In addition, although more controversial, increasing evidence supports the use of HAART during the acute HIV seroconversion syndrome. An "immune reconstitution syndrome" has been newly described for patients in the early phases of treatment with HAART who develop tuberculosis, M avium complex, and cytomegalovirus disease. Accumulating data support the use of hydroxyurea, an agent with a long history in the field of myeloproliferative disorders, for the treatment of HIV. Newer agents, particularly abacavir and adefovir dipivoxil, are available through expanded access protocols, and their roles are being defined and clarified.     

Home use of a functional electrical stimulation system for standing and mobility in adolescents with spinal cord injury

OBJECTIVE: Functional electrical stimulation (FES) is a technology that may allow some patients with spinal cord injury (SCI) to integrate standing and upright mobility with wheelchair mobility. The purpose of this study was to document the patterns of home and community use of a FES system for standing and mobility. DESIGN: A telephone questionnaire was administered every 1 to 4 weeks for a minimum of 1 year. An interview was given at the end of the study to probe the motivators and barriers to home use. SETTING: Training for use of the FES system was performed in an inpatient pediatric rehabilitation setting. Data collection began after the subjects were discharged to home. PARTICIPANTS: Five adolescents with complete, thoracic-level SCI. INTERVENTION: Subjects participated in a program of FES exercise followed by training in basic mobility skills such as standing transfers, maneuvering, level ambulation, one-handed and reaching activities, and stair ascent/descent. MAIN OUTCOME MEASURE: The frequency with which the FES system was used at home and the activities for which it was utilized were documented. Motivators and barriers to FES home use were examined. RESULTS: Subjects donned the FES system on the average once every 3 to 4 days. Between 51% and 84% of the times donned, the system was used for exercise. The remaining times it was used for standing activities, most commonly reaching, one-handed tasks, and standing for exercise. "Motivators" included being able to do things that would otherwise be difficult, perceiving a healthful benefit or a sense of well-being from standing and exercise, and feeling an obligation to stand as a participant in a research study. "Barriers" to FES use included not finding time to use the system, having difficulty seeing opportunities to stand, and being reluctant to wear the FES system all day.     

Periodic health examination, 1996 update: 2. Screening for chlamydial infections. Canadian Task Force on the Periodic Health Examination

OBJECTIVE: To update the 1984 recommendations of the Canadian Task Force on the Periodic Health Examination on the routine screening of asymptomatic patients for infection with Chlamydia trachomatis. OPTIONS: Screening, with the use of culture or nonculture tests, of the general population, of certain high-risk groups or of all pregnant women; or no routine screening. OUTCOMES: Rates of asymptomatic and symptomatic chlamydial infection, perinatal complications, longterm complications of infection (i.e., pelvic inflammatory disease, infertility and ectopic pregnancy), coinfection with other sexually transmitted diseases, disease spread, hospital care, complications of therapy and costs of infection and of screening. EVIDENCE: Search of MEDLINE for articles published between Jan. 1, 1983, and Dec. 31, 1995, with the use of the major MeSH heading "chlamydial infections," references from recent review articles and recommendation by other organizations. VALUES: The evidence-based methods of the Canadian Task Force on the Periodic Health Examination were used. Advice from reviewers and experts and recommendations of other organizations were taken into consideration. Prevention of symptomatic disease and decreased overall costs were given high values. BENEFITS, HARMS AND COSTS: The greatest potential benefits of screening asymptomatic patients for chlamydial infections are the prevention of complications, especially infertility and perinatal complications, and the prevention of disease spread. There is no evidence that screening of the general population for chlamydial infections leads to a reduction in complications, and screening may increase costs. However, there is evidence that annual screening of selected high-risk groups and of pregnant women during the first trimester is beneficial in preventing symptoms and reducing the overall cost resulting from infection. RECOMMENDATIONS: There is fair evidence to support screening and treatment of pregnant women during the first trimester (grade B recommendation) as well as annual screening and treatment of high-risk groups (sexually active women less than 25 years of age, men or women with new or multiple sexual partners during the preceding year, women who use nonbarrier contraceptive methods and women who have symptoms of chlamydial infection: cervical friability, mucopurulent cervical discharge or intermenstrual bleeding; grade B recommendation). There is fair evidence to exclude routine screening of the general population (grade D recommendation). VALIDATION: These recommendations are similar to those of the US Preventive Services Task Force and the US Centers for Disease Control and Prevention, Atlanta. SPONSOR: These guidelines were developed and endorsed by the Canadian Task Force on the Periodic Health Examination, which is funded by Health Canada and the National Health Canada and the National Health Research and Development Program. The principal author (H.D.D.) was supported in part by the Ontario Ministry of Health and the Canadian Infectious Diseases Society Lilly Fellowship.     

A comparative evaluation of interactive segmentation algorithms

In this paper we present a comparative evaluation of four popular interactive segmentation algorithms. The evaluation was carried out as a series of user-experiments, in which participants were tasked with extracting 100 objects from a common dataset: 25 with each algorithm, constrained within a time limit of 2 min for each object. To facilitate the experiments, a “scribble-driven” segmentation tool was developed to enable interactive image segmentation by simply marking areas of foreground and background with the mouse. As the participants refined and improved their respective segmentations, the corresponding updated segmentation mask was stored along with the elapsed time. We then collected and evaluated each recorded mask against a manually segmented ground truth, thus allowing us to gauge segmentation accuracy over time. Two benchmarks were used for the evaluation: the well-known Jaccard index for measuring object accuracy, and a new fuzzy metric, proposed in this paper, designed for measuring boundary accuracy. Analysis of the experimental results demonstrates the effectiveness of the suggested measures and provides valuable insights into the performance and characteristics of the evaluated algorithms.     

A bounded distance metric for comparing tree structure

Comparing tree-structured data for structural similarity is a recurring theme and one on which much effort has been spent. Most approaches so far are grounded, implicitly or explicitly, in algorithmic information theory, being approximations to an information distance derived from Kolmogorov complexity. In this paper we propose a novel complexity metric, also grounded in information theory, but calculated via Shannon's entropy equations. This is used to formulate a directly and efficiently computable metric for the structural difference between unordered trees. The paper explains the derivation of the metric in terms of information theory, and proves the essential property that it is a distance metric. The property of boundedness means that the metric can be used in contexts such as clustering, where second-order comparisons are required. The distance metric property means that the metric can be used in the context of similarity search and metric spaces in general, allowing trees to be indexed and stored within this domain. We are not aware of any other tree similarity metric with these properties.     

A Multi‐Autonomous Underwater Vehicle System for Autonomous Tracking of Marine Life

This paper presents a multi‐autonomous underwater vehicle system capable of cooperatively and autonomously tracking and following marine targets (i.e., fish) tagged with an acoustic transmitter. The AUVs have been equipped with stereo‐hydrophones that receive signals broadcasted by the acoustic transmitter tags to enable real‐time calculation of bearing‐to‐tag and distance‐to‐tag measurements. These measurements are shared between AUVs via acoustic modem and fused within each AUV's particle filter for estimating the target's position. The AUVs use a leader/follower multi‐AUV control system to enable the AUVs to drive toward the estimated target state by following collision‐free paths. Once within the local area of the target, the AUVs circumnavigate the target state until it moves to another area. The system builds on previous work by incorporating a new SmartTag package that can be attached to an individual's dorsal fin. The SmartTag houses a full inertial measurement unit (INU), video logger, acoustic transmitter, and timed release mechanism. After real‐time AUV tracking experiments, the SmartTag is recovered. Logged IMU data are fused with logged AUV‐obtained acoustic tag measurements within a particle filter to improve state estimation accuracy. This improvement is validated through a series of multi‐AUV shark and boat tracking experiments conducted at Santa Catalina Island, California. When compared with previous work that did not use the SmartTag package, results demonstrated a decrease in mean position estimation error of 25–75%, tag orientation estimation errors dropped from 80° to 30° , the sensitivity of mean position error with respect to distance to the tag was less by a factor of 50, and the sensitivity of mean position error with respect to acoustic signal reception frequency to the tag was 25 times less. These statistics demonstrate a large improvement in the system's robustness when the SmartTag package is used.     

The effect of pre-polymer/cross-linker storage on the elasticity and reliability of PDMS microfluidic devices

Polydimethylsiloxane (PDMS) is a commonly used material in biomedical engineering (Sollier et al. in Lab Chip 11(22):3752–3765, 2011; Palchesko et al. in PLoS ONE 7(12):e51499, 2012; Berthier et al. in Lab Chip 12(7):1224–1237, 2012). Its elastic nature makes PDMS especially attractive for microfluidic large-scale integration (mLSI) technology where micromechanical valves are actuated by deflecting a PDMS membrane under pressure. Therefore, understanding and control of PDMS elastic properties have commercial and scientific significance. In this study, we have investigated the effects of pre-polymer/cross-linker storage conditions on the mechanical properties of cured PDMS films as well as on microfluidic devices. We have showed that when the uncured components of PDMS are exposed to different humidity conditions, the elasticity of the PDMS changes and this is revealed as a change in the Young’s modulus of the cured PDMS. The high humidity (~85%) exposure for 24 h causes PDMS to become softer as confirmed by a significant decrease in the Young’s modulus values from 1.2 to 0.9 MPa. Furthermore, as the PDMS is exposed to high humidity conditions for longer periods (72 h), the Young’s modulus decreases down to 0.7 MPa. We found that exposing only the pre-polymer PDMS (Part A) to humid air does not alter the cured PDMS properties significantly, whereas exposure of the cross-linker (Part B) is responsible for the elasticity change. We have strictly controlled the storage humidity to build more reliable microfluidic chips using mLSI. As a result, actuation pressure of valves (10 psi) and defects of devices (in <30% of chips) are significantly reduced. These results suggest that to improve the manufacturing yield and reliability of PDMS devices, storage humidity should be controlled immediately after the material synthesis.     

Augmenting interaction and cognition using agent architectures and technology inspired by psychology and social worlds

Intelligent agents can play a pivotal role in providing both software systems and augmented interfaces, to individual users from all walks of life, to utilise the Internet 24 h a day, 7 days a week (24×7), including interaction with other users, over both wireless and broadband infrastructures. However, traditional approaches to user modelling are not adequate for this purpose, as they mainly account for a generic, approximate, idealised user. New user models are therefore required to be adaptable for each individual and flexible enough to represent the diversity of all users using information technology. Such models should be able to cover all aspects of an individual’s life—those aspects of most interest to the individual user themselves. This paper describes a novel intelligent agent architecture and methodology both called ShadowBoard, based on a complex user model drawn from analytical psychology. An equally novel software tool, called the DigitalFriend based on ShadowBoard, is also introduced. This paper illustrates how aspects of user cognition can be outsourced, using, for example, an internationalised book price quoting agent. The Locales Framework from Computer Supported Co-operative Work is then used to understand the problematic aspects of interaction involved in complex social spaces, identifying specific needs for technology intervention in such social spaces, and to understand how interactions amongst mobile users with different abilities might be technically assisted in such spaces. In this context, the single user-centred multi-agent technology demonstrated in the DigitalFriend is adapted to a multi-user system dubbed ShadowPlaces. The aim of ShadowPlaces is to outsource some of the interaction necessary, for a group of mobile individuals with different abilities to interact cooperatively and effectively in a social world, supported by wireless networks and backed by broadband Internet services. An overview of the user model, the architecture and methodology (ShadowBoard) and the resulting software tool (the DigitalFriend) is presented, and progress on ShadowPlaces—the multi-user version—is outlined.