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1.  Patient Perception of Natural Orifice Transluminal Endoscopic Surgery in an Endoscopy Screening Program in Korea 
Yonsei Medical Journal  2012;53(5):960-967.
Purpose
Natural orifice transluminal endoscopic surgery (NOTES) is a new method of accessing intracavitary organs in order to minimize pain by avoiding incisions in the body wall. The aim of this study is to determine patients' acceptance of NOTES in Korea and to compare their views about laparoscopic surgery and NOTES for benign and malignant diseases.
Materials and Methods
The target number of total subjects was calculated to be 540. The subjects were classified into 18 sub-groups based on age groups, gender, and history of prior surgery. The questionnaire elicited information about demographic characteristics, medical check-ups, diseases, endoscopic and surgical histories, marital status and childbirth, the acceptance of NOTES, and the preferred routes for NOTES. In addition, the subjects chose laparoscopic surgery or NOTES for a hypothetical cholecystectomy and rectal cancer surgery, and responded to questions regarding the acceptable complication rate of NOTES, the appropriate cost of NOTES, and the reason(s) why they did not select NOTES.
Results
486 of 540 patients (90.0%) who agreed to participate in this study completed the questionnaire. NOTES was preferred by the following patients: elderly; a history of treatment due to a disease; having regular check-ups; and a history of an endoscopic procedure (p<0.05). The most preferred route for NOTES was the stomach (67.1%). Eighty-four percent of the patients choosing NOTES responded that the complication rate of the new surgical method should be the same or lower than laparoscopic surgery. Vague anxiety over a new surgical method was the most common reason why NOTES was not selected in benign and malignant diseases (64% and 73%), respectively.
Conclusion
Patients appear to be interested in the potential benefits of NOTES and would embrace it if their concerns about safety are met. We believe that qualified surgical endoscopists can meet these safety concerns, and that NOTES development has the potential to flourish.
doi:10.3349/ymj.2012.53.5.960
PMCID: PMC3423838  PMID: 22869479
NOTES; endoscopy; surgery; patient perception; survey
2.  Natural orifice surgery applied for colorectal diseases 
Clinical natural orifice surgery has been applied to abdominal surgery in recent years, mostly using transvaginal and transgastric access. Rectal and transcolonic natural orifice transluminal endoscopic surgery (NOTES) were tested in animal and cadaver models by a few research groups. Despite the potential advantages of transcolonic NOTES for colorectal diseases, it has not yet been clinically applied. The first successful series of human applications of transcolonic NOTES in the literature from the NOTES Research Group in Brazil provide new possibilities in the field in new transrectal procedures for rectal cancer and benign disease. Successful first human reports on Transcolonic NOTES potentially brings new frontiers and applications for minimally invasive surgery. The treatment of colorectal diseases through flexible Perirectal NOTES Access is a promising new approach alongside existing laparoscopic and open surgery to improve patient care.
doi:10.4240/wjgs.v2.i2.35
PMCID: PMC2999213  PMID: 21160847
Rectal cancer; Total mesorectal excision; Colorectal surgery; Natural orifice surgery; Natural orifice transluminal endoscopic surgery; Minimally invasive surgery.
3.  Evaluating the impact of structured text and templates in ambulatory nursing. 
This evaluation looks at the use of templates for entering structured text nursing notes that generate both a legal text note that is the chart record and an underlying coded form of the note to support analysis and research. This study reflects the first phase of a prototype project of an integrated, computerized health record. Templates are notes that have been prewritten using a standard clinical vocabulary. Templates can be used as the basis of a new clinical note and can be either signed unchanged or modified to represent variations in clinical presentation. The prototype setting is a Primary Care clinic where both physicians and nurses are using the computer to enter clinical notes. In the prototype clinic team, nursing utilized the CPR for 100% of all documentation from day one. Use of templates was found to be the most frequent method of initiating a note.
PMCID: PMC2579186  PMID: 8563381
4.  Quantifying clinical narrative redundancy in an electronic health record 
Objective
Although electronic notes have advantages compared to handwritten notes, they take longer to write and promote information redundancy in electronic health records (EHRs). We sought to quantify redundancy in clinical documentation by studying collections of physician notes in an EHR.
Design and methods
We implemented a retrospective design to gather all electronic admission, progress, resident signout and discharge summary notes written during 100 randomly selected patient admissions within a 6 month period. We modified and applied a Levenshtein edit-distance algorithm to align and compare the documents written for each of the 100 admissions. We then identified and measured the amount of text duplicated from previous notes. Finally, we manually reviewed the content that was conserved between note types in a subsample of notes.
Measurements
We measured the amount of new information in a document, which was calculated as the number of words that did not match with previous documents divided by the length, in words, of the document. Results are reported as the percentage of information in a document that had been duplicated from previously written documents.
Results
Signout and progress notes proved to be particularly redundant, with an average of 78% and 54% information duplicated from previous documents respectively. There was also significant information duplication between document types (eg, from an admission note to a progress note).
Conclusion
The study established the feasibility of exploring redundancy in the narrative record with a known sequence alignment algorithm used frequently in the field of bioinformatics. The findings provide a foundation for studying the usefulness and risks of redundancy in the EHR.
doi:10.1197/jamia.M3390
PMCID: PMC2995640  PMID: 20064801
5.  Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication 
As routine use of on-line progress notes in US Department of Veterans Affairs facilities grew rapidly in the past decade, health information managers and clinicians began to notice that authors sometimes copied text from old notes into new notes. Other sources of duplication were document templates that inserted boilerplate text or patient data into notes. Word-processing and templates aided the transition to electronic notes, but enabled author copying and sometimes led to lengthy, hard-to-read records stuffed with data already available on-line. Investigators at a VA center recognized for pioneering a fully electronic record system analyzed author copying and template-generated duplication with adapted plagiarism-detection software. Nine percent of progress notes studied contained copied or duplicated text. Most copying and duplication was benign, but some introduced misleading errors into the record and some seemed possibly unethical or potentially unsafe. High-risk author copying occurred once for every 720 notes, but one in ten electronic charts contained an instance of high-risk copying. Careless copying threatens the integrity of on-line records. Clear policies, practitioner consciousness-raising and development of effective monitoring procedures are recommended to protect the value of electronic patient records.
PMCID: PMC1480345  PMID: 14728176
6.  The ANKLe Score: An Audit of Otolaryngology Emergency Clinic Record Keeping 
INTRODUCTION
Accurate and legible medical records are essential to good quality patient care. Guidelines from The Royal College of Surgeons of England (RCSE) state the content required to form a complete medical record, but do not address legibility. An audit of otolaryngology emergency clinic record keeping was performed using a new scoring system.
PATIENTS AND METHODS
The Adjusted Note Keeping and Legibility (ANKLe) score was developed as an objective and quantitative method to assess both the content and legibility of case notes, incorporating the RCSE guidelines. Twenty consecutive otolaryngology emergency clinic case notes from each of 7 senior house officers were audited against standards for legibility and content using the ANKLe score. A proforma was introduced to improve documentation and handwriting advice was given. A further set of 140 notes (20 notes for each of the 7 doctors) was audited in the same way to provide feedback.
RESULTS
The introduction of a proforma and advice on handwriting significantly increased the quality of case note entries in terms of content, legibility and overall ANKLe score.
CONCLUSIONS
Accurate note keeping can be improved by the use of a proforma. The legibility of handwriting can be improved using simple advice. The ANKLe score is an objective assessment tool of the overall quality of medical note documentation which can be adapted for use in other specialties.
doi:10.1308/003588408X261537
PMCID: PMC2430432  PMID: 18430339
Medical audit; Medical records; Handwriting; Quality
7.  In vivo miniature robots for natural orifice surgery: State of the art and future perspectives 
Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.
doi:10.4240/wjgs.v2.i6.217
PMCID: PMC2999241  PMID: 21160878
Robotic surgery; In vivo robots; Natural orifice surgery; Robotic surgical platforms
8.  Natural orifice transluminal endoscopic surgery in urology: Review of the world literature 
Urology Annals  2012;4(1):1-5.
Natural orifice transluminal endoscopic surgery (NOTES) has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES.
doi:10.4103/0974-7796.91611
PMCID: PMC3271442  PMID: 22346092
Natural orifice transluminal endoscopic surgery; urology; world literature
9.  Effect of field notes on confidence and perceived competence 
Canadian Family Physician  2012;58(6):e352-e356.
Abstract
Objective
To evaluate the effectiveness of field notes in assessing teachers’ confidence and perceived competence, and the effect of field notes on residents’ perceptions of their development of competence.
Design
A faculty and resident survey completed 5 years after field notes were introduced into the program.
Setting
Five Dalhousie University family medicine sites—Fredericton, Moncton, and Saint John in New Brunswick, and Halifax and Sydney in Nova Scotia.
Participants
First- and second-year family medicine residents (as of May 2009) and core family medicine faculty.
Main outcome measures
Residents’ outcome measures included beliefs about the effects of field notes on performance, learning, reflection, clinical skills development, and feedback received. Faculty outcome measures included beliefs about the effect of field notes on guiding feedback, teaching, and reflection on clinical practice.
Results
Forty of 88 residents (45.5%) participated. Fifteen of 50 faculty (30.0%) participated, which only permitted a discussion of trends for faculty. Residents believed field note–directed feedback reinforced their performance (81.1%), helped them learn (67.6%), helped them reflect on practice and learning (66.7%), and focused the feedback they received, making it more useful (62.2%) (P < .001 for all); 63.3% believed field note–directed feedback helped with clinical skills development (P < .01). Faculty believed field notes helped to provide more focused (86.7%) and effective feedback (78.6%), improved teaching (75.0%), and encouraged reflection on their own clinical practice (73.3%).
Conclusion
Most surveyed residents believed field note use improved the feedback they received and helped them to develop competence through improved performance, learning, reflection, and clinical skills development. The trends from faculty information suggested faculty believed field notes were an effective teaching, feedback, and reflection tool.
PMCID: PMC3374708  PMID: 22700743
10.  Exploration of GPs' views and use of the fit note: a qualitative study in primary care 
The British Journal of General Practice  2012;62(598):e363-e370.
Background
Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work — the ‘fit note’ — was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews.
Aim
To explore GPs' views and use of the fit note during its first year of operation.
Design and setting
Qualitative interview study of GPs based in different geographical locations across the UK.
Method
GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis.
Results
Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs' operation of sickness certification. Feedback over the fit note's impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed.
Conclusion
A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.
doi:10.3399/bjgp12X641483
PMCID: PMC3338058  PMID: 22546596
general practice; health policy; qualitative research; sick leave; sickness certification
11.  The acoustic and perceptual cues affecting melody segregation for listeners with a cochlear implant 
Our ability to listen selectively to single sound sources in complex auditory environments is termed “auditory stream segregation.”This ability is affected by peripheral disorders such as hearing loss, as well as plasticity in central processing such as occurs with musical training. Brain plasticity induced by musical training can enhance the ability to segregate sound, leading to improvements in a variety of auditory abilities. The melody segregation ability of 12 cochlear-implant recipients was tested using a new method to determine the perceptual distance needed to segregate a simple 4-note melody from a background of interleaved random-pitch distractor notes. In experiment 1, participants rated the difficulty of segregating the melody from distracter notes. Four physical properties of the distracter notes were changed. In experiment 2, listeners were asked to rate the dissimilarity between melody patterns whose notes differed on the four physical properties simultaneously. Multidimensional scaling analysis transformed the dissimilarity ratings into perceptual distances. Regression between physical and perceptual cues then derived the minimal perceptual distance needed to segregate the melody. The most efficient streaming cue for CI users was loudness. For the normal hearing listeners without musical backgrounds, a greater difference on the perceptual dimension correlated to the temporal envelope is needed for stream segregation in CI users. No differences in streaming efficiency were found between the perceptual dimensions linked to the F0 and the spectral envelope. Combined with our previous results in normally-hearing musicians and non-musicians, the results show that differences in training as well as differences in peripheral auditory processing (hearing impairment and the use of a hearing device) influences the way that listeners use different acoustic cues for segregating interleaved musical streams.
doi:10.3389/fpsyg.2013.00790
PMCID: PMC3818467  PMID: 24223563
auditory streaming; cochlear implant; music training; melody segregation; hearing impairment; pitch; loudness; timbre
12.  Single-incision laparoscopic surgery - current status and controversies 
Scarless surgery is the Holy Grail of surgery and the very raison d’etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a ‘scarless’ effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.
doi:10.4103/0972-9941.72360
PMCID: PMC3002008  PMID: 21197236
E-NOTES; LESS; single-incision laparoscopy; single-port access
13.  Fit for purpose? Using the fit note with patients with chronic pain: a qualitative study 
The British Journal of General Practice  2011;61(593):e794-e800.
Background
Staying in work may benefit patients with chronic pain, but can be difficult for GPs to negotiate with patients and their employers. The new fit note is designed to help this process, but little is known of how it is operating.
Aim
To explore GPs' views on the fit note, with particular reference to sickness certification for patients with chronic pain.
Design and setting
Qualitative study using semi-structured interviews in eight primary care trusts in south-west England.
Method
In-depth interviews with 13 GPs.
Results
GPs reported that the rationale behind the fit note is sound and that it may help patients with chronic pain to return to work earlier. However, GPs also reported barriers to successful fit note use, including the need to preserve doctor–patient relationships, inconsistent engagement from employers, GPs' lack of specialist occupational health knowledge, issues with fit note training, and whether a new form can achieve cultural shift.
Conclusion
While doctors agree that good work improves health outcomes, they do not think that fit notes will greatly alter sickness-certification rates without more concerted initiatives to manage the tripartite negotiation between doctor, patient, and employer.
doi:10.3399/bjgp11X613133
PMCID: PMC3223777  PMID: 22137416
chronic disease; general practice; pain; sick leave
14.  Redundancy-Aware Topic Modeling for Patient Record Notes 
PLoS ONE  2014;9(2):e87555.
The clinical notes in a given patient record contain much redundancy, in large part due to clinicians’ documentation habit of copying from previous notes in the record and pasting into a new note. Previous work has shown that this redundancy has a negative impact on the quality of text mining and topic modeling in particular. In this paper we describe a novel variant of Latent Dirichlet Allocation (LDA) topic modeling, Red-LDA, which takes into account the inherent redundancy of patient records when modeling content of clinical notes. To assess the value of Red-LDA, we experiment with three baselines and our novel redundancy-aware topic modeling method: given a large collection of patient records, (i) apply vanilla LDA to all documents in all input records; (ii) identify and remove all redundancy by chosing a single representative document for each record as input to LDA; (iii) identify and remove all redundant paragraphs in each record, leaving partial, non-redundant documents as input to LDA; and (iv) apply Red-LDA to all documents in all input records. Both quantitative evaluation carried out through log-likelihood on held-out data and topic coherence of produced topics and qualitative assessement of topics carried out by physicians show that Red-LDA produces superior models to all three baseline strategies. This research contributes to the emerging field of understanding the characteristics of the electronic health record and how to account for them in the framework of data mining. The code for the two redundancy-elimination baselines and Red-LDA is made publicly available to the community.
doi:10.1371/journal.pone.0087555
PMCID: PMC3923754  PMID: 24551060
15.  NOTES, MANOS, SILS and other new laparoendoscopic techniques 
A new way of opening a body cavity can be a revolution in surgery. In 1980s, laparoscopy changed how surgeons had been working for years. Natural orifice translumenal endoscopic surgery (NOTES), minilaparoscopy-assisted natural orifice surgery (MANOS), single incision laparoscopic surgery (SILS) and other new techniques are the new paradigm in our way of operating in the 21st century. The development of these techniques began in the late 90s but they have not had enough impact to develop and evolve. Parallels between the first years of laparoscopy and NOTES can be made. Working for an invisible surgery, not only for cosmesis but for a less invasive surgery, is the target of NOTES, MANOS and SILS performed by surgeons and endoscopists over the last 10 years. The future flexible endoscopic platforms and the fusion between laparoscopic instruments and devices and robotic surgery will be a great advance for “scarless surgery”.
doi:10.4253/wjge.v4.i6.212
PMCID: PMC3377862  PMID: 22720121
Laparoscopy; Endoscopy; Natural orifice translumenal endoscopic surgery; Single incision laparoscopic surgery; Minilaparoscopy-assisted natural orifice surgery; Flexible endoscopy
16.  Relation between epistaxis, external nasal deformity, and septal deviation following nasal trauma 
Emergency Medicine Journal : EMJ  2005;22(11):778-779.
Objectives: To find if the presence of epistaxis after nasal trauma can be used to predict post-traumatic external nasal deformity or a symptomatic deviated nasal septum.
Methods: Retrospective analysis of all patients seen in the fractured nose clinic by the first author between 17 October 2003 and 27 February 2004. Presence of epistaxis, newly developed external nasal deformity, and the presence of a deviated nasal septum with new symptoms of nasal obstruction were noted.
Results: A total of 139 patients were included in the study. Epistaxis following injury was noted in 106 (76%). Newly developed external nasal deformity was noted in 71 (51%), and 33 (24%) had a deviated nasal septum with new symptoms of nasal obstruction. Of the 106 patients with post-trauma epistaxis, 50 (67%) had newly developed external nasal deformity and of the 33 patients without post-traumatic epistaxis, 11 (33%) had nasal deformity (p<0.05). Post-trauma epistaxis was not associated with the presence of a newly symptomatic deviated septum (25% in patients with epistaxis after injury versus 18% if there was no epistaxis).
Conclusions: Presence of epistaxis after nasal trauma is associated with a statistically significant increase in external nasal deformity. However, one third of patients without epistaxis following nasal trauma also had external nasal deformity and hence all patients with a swollen nose after injury, irrespective of post-trauma epistaxis, still need to be referred to the fractured nose clinic.
doi:10.1136/emj.2004.018994
PMCID: PMC1726610  PMID: 16244333
17.  Natural orifice transluminal endoscopic surgery: New minimally invasive surgery come of age 
Although in the past two decades, laparoscopic surgery, considered as a great revolution in the minimally invasive surgery field, has undergone major development worldwide, another dramatic surgical revolution has quietly appeared in recent years. Ever since Kalloo’s first report on transgastric peritoneoscopy in a porcine model in 2004, interest in a new surgical procedure named natural orifice transluminal endoscopic surgery (NOTES) has blossomed worldwide. Considering that a NOTES procedure could theoretically avoid any abdominal incision, operation-related pain and scarring, many surgeons and endoscopists have been enthusiastic in their study of this new technique. In recent years, several NOTES studies have been carried out on porcine models and even on humans, including transvaginal cholecystectomy, transgastric appendectomy, transvaginal appendectomy, and transvesical peritoneoscopy. So what is the current situation of NOTES and how many challenges do we still face? This review discusses the current research progress in NOTES.
doi:10.3748/wjg.v17.i39.4382
PMCID: PMC3218151  PMID: 22110263
Laparoscopic surgery; Natural orifice transluminal endoscopic surgery; Endoscopy
18.  Advancing medicine one research note at a time: the educational value in clinical case reports 
BMC Research Notes  2012;5:293.
A case report—a brief written note that describes unique aspects of a clinical case—provides a significant function in medicine given its rapid, succinct, and educational contributions to scientific literature and clinical practice. Despite the growth of, and emphasis on, randomized clinical trials and evidenced-based medicine, case reports continue to provide novel and exceptional knowledge in medical education. The journal BMC Research Notes introduces a new “case reports” section to provide the busy clinician with a forum in which to document any authentic clinical case that provide educational value to current clinical practice. The aim is for this article type to be reviewed, wherever possible, by specialized Associate Editors for the journal, in order to provide rapid but thorough decision making. New ideas often garnered by and documented in case reports will support the advancement of medical science — one research note at a time.
doi:10.1186/1756-0500-5-293
PMCID: PMC3392736  PMID: 22697904
19.  Failure to deliver hepatitis B vaccine: confessions from a genitourinary medicine clinic. 
BMJ : British Medical Journal  1991;303(6794):97-101.
OBJECTIVE--To audit hepatitis B immunisation of homosexual or bisexual men in a genitourinary medicine clinic. DESIGN--Retrospective case note review of all homosexual and bisexual men presenting to a genitourinary clinic as new patients during 12 months in 1988 and follow up review of notes to May 1990. SETTING--One department of genitourinary medicine, Middlesex Hospital. PATIENTS--758 homosexual or bisexual men, of whom 207 started a course of hepatitis B vaccine in 1988. Case notes were unavailable for one patient. MAIN OUTCOME MEASURES--The proportion of patients screened for hepatitis B virus markers, the proportion of susceptible patients immunised, the proportion completing the vaccine course, and the proportion rendered immune. RESULTS--25 men had been previously tested for hepatitis markers; of the 732 not previously tested, 440 (60.1%) were screened for hepatitis B markers. 207 (69%) of the 300 patients without hepatitis B serological markers started the vaccine course, and 141 (68%) completed it, with 75 (84%) of the 89 tested after immunisation being immune. An estimated 24% of susceptible new patients were rendered immune as a result of the immunisation policy. Patients who presented with a further episode of a sexually transmitted disease were more likely to have been screened (25% v 12%, p less than 0.0001) and immunised (31% v 18% p = 0.02); those known or found to be positive for HIV antibody were more likely to have been screened (23% v 14%, p = 0.047) but less likely to have been immunised (6% v 17%, p = 0.004). CONCLUSIONS--The major failure was that in not screening; failure to immunise patients found to be susceptible and failure of compliance with the vaccine course contributed. Non-response to the vaccine was of minor importance. Improvements in vaccine delivery are required. IMPLICATIONS--Other providers should be encouraged to review their performance.
PMCID: PMC1670616  PMID: 1830505
20.  Selective spread of herpes simplex virus in the central nervous system after ocular inoculation. 
Journal of Virology  1989;63(11):4756-4761.
The spread of herpes simplex virus (HSV) was studied in the mouse central nervous system (CNS) after ocular inoculation. Sites of active viral replication in the CNS were identified by autoradiographic localization of neuronal uptake of tritiated thymidine. Labeled neurons were first noted in the CNS at 4 days postinoculation in the Edinger-Westphal nucleus, ipsilateral spinal trigeminal nucleus, pars caudalis, pars interpolaris, and ipsilateral dorsal horn of the rostral cervical spinal cord. By 5 days postinoculation, additional sites of labeling included the seventh nerve nucleus, nucleus locus coeruleus, and the nuclei raphe magnus and raphe pallidus. None of these sites are contiguous to nuclei infected at 4 days, but all are synaptically related to these nuclei. By 7 days postinoculation, no new foci of labeled cells were noted in the brain stem, but labeled neurons were noted in the amygdala, hippocampus, and somatosensory cortex. Neurons in both the amygdala and hippocampus receive axonal projections from the locus coeruleus. On the basis of these findings, we conclude that the spread of HSV in the CNS after intracameral inoculation is not diffuse but is restricted to a small number of noncontiguous foci in the brain stem and cortex which become infected in a sequential fashion. Since these regions are synaptically related, the principal route of the spread of HSV in the CNS after ocular infection appears to be along axons, presumably via axonal transport rather than by local spread.
Images
PMCID: PMC251112  PMID: 2552151
21.  Surgery for Fractured Neck of Femur – are Patients Adequately Consented? 
INTRODUCTION
Obtaining valid consent is a legal and ethical obligation when performing any procedure in clinical practice. This study was performed to identify the validity and effectiveness of the new consent form and any potential improvement that could be made when taking consent.
PATIENTS AND METHODS
Case notes of 173 patients undergoing surgery for fractured neck of femur were retrospectively reviewed. Risks and complications of the surgery as listed on the consent form were noted. Sixty-five cases were excluded from the study as they had either old consent forms with no risks recorded or a consent form signed by a consultant due to patient inability to consent. Six of the consent forms could not be located in the notes. This left 102 consent forms to be analysed.
RESULTS
The number of risks documented on each form ranged from 0–8 (mean, 3.92). No risks were recorded in 2 of these 102 forms. Most commonly recorded risks were infection (95.1%), DVT/PE (81.4%) and failure of procedure (59.8%). It was shown that many of the consent forms analysed did not have all the serious or frequently occurring risks recorded on them and that a large proportion of the forms had acronyms or phrases that may mean nothing to the patient. Comparison of documented risks for different hip surgery were made using Fisher's exact test showing no significant difference between the risks recorded on the forms for each type of procedure.
CONCLUSIONS
Although documentation of risks has been improved compared to old consent forms, patients are not necessarily given the most appropriate information to ensure consent is valid. Further refining of consent forms may be necessary to ensure that all major risks are explained and understood by patients and that there is satisfactory recording of this information.
doi:10.1308/003588407X160846
PMCID: PMC1963537  PMID: 17316526
Consent forms; Fracture; Neck of femur; Hip surgery
22.  How well do family practitioner committee and general practice records agree? Experience in a semi-rural practice. 
General practice notes may be inaccurate for various reasons. A study was carried out in one semi-rural practice to investigate the agreement between records held by the family practitioner committee and those kept in the practice. Details on the practice notes and the family practitioner committee list were compared for 800 patients. The details examined included name, sex, date of birth, address and National Health Service number. While 58% of records agreed, discrepancies occurred in 339 records (42%). The most common discrepancies concerned the patient's address (30.6%), date of birth (9.4%) and NHS number (8.0%). Nearly 5% of the practice notes appeared to be for patients who were no longer on the practice list or dependent on its care. These findings have implications under the new general practitioner contract where screening programmes, target related payments, and increased capitation fees require accurate practice records.
PMCID: PMC1371691  PMID: 1747269
23.  Clinicians’ Perceptions of Usability of eNote 
The purpose of this evaluation was to assess perceptions of usability of a new semi-structured electronic clinical note. Two focus groups were held, one with attending physicians and one with residents. Physicians described their experiences with eNote and their perceptions about the system. Transcripts of the focus groups underwent content analysis, and four major themes emerged. These were “time”, “hardware-system issues”, “eNote application issues”, and “patients’ perceptions.”
PMCID: PMC1560454  PMID: 16779260
24.  Creating a note classification scheme for a multi-institutional electronic medical record 
How notes are categorized in an electronic medical record (EMR) influences how rapidly users can locate documents and enter new ones, whether algorithmic search for chart deficiencies is possible, and the ease of incorporating collections of existing notes. We balanced these competing needs when developing a note classification scheme for the Online Record of Clinical Activity (ORCA) electronic medical record at the University of Washington.
PMCID: PMC1480190  PMID: 14728472
25.  A Study of Actions in Operative Notes 
AMIA Annual Symposium Proceedings  2012;2012:1431-1440.
Operative notes contain rich information about techniques, instruments, and materials used in procedures. To assist development of effective information extraction (IE) techniques for operative notes, we investigated the sublanguage used to describe actions within the operative report ‘procedure description’ section. Deep parsing results of 362,310 operative notes with an expanded Stanford parser using the SPECIALIST Lexicon resulted in 200 verbs (92% coverage) including 147 action verbs. Nominal action predicates for each action verb were gathered from WordNet, SPECIALIST Lexicon, New Oxford American Dictionary and Stedman’s Medical Dictionary. Coverage gaps were seen in existing lexical, domain, and semantic resources (Unified Medical Language System (UMLS) Metathesaurus, SPECIALIST Lexicon, WordNet and FrameNet). Our findings demonstrate the need to construct surgical domain-specific semantic resources for IE from operative notes.
PMCID: PMC3540433  PMID: 23304423

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