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Research capacity strengthening in the South.

Active promotion of evidence-based decision-making at all levels of the health field is a necessary step in the direction of improving the health of the population. Recent studies have shown that the burden of disease in developing countries is high particularly the burden of infectious, communicable and non-communicable diseases and health problems of mothers and children. There is presently, a mismatch between this increased disease and health burden and the technical and human capacity of developing countries to use existing knowledge and to generate new knowledge to combat these diseases and health problems. It is therefore necessary to assist developing countries to build indigenous research capability so they can undertake studies in their own national settings the results of which will lead to the development of appropriate control strategies in their countries. Building indigenous research capacity will enable developing country scientists to translate results of studies carried out elsewhere into their individual national settings. Eventually results of such studies will increase the global knowledge base about the particular health problems and contribute to finding appropriate solutions to them. The research will, finally, increase knowledge-based decision-making by their health leadership of the country. This paper has set out to describe some experiences in capacity strengthening over the last few decades and to propose from these, mechanisms for building these capacities in a sustainable manner. This paper has described the steps in capability strengthening with special emphasis on identification of trainees, their training and deployment on return. The paper has described mechanisms of research sustainability including creation of suitable career structures, remuneration of researchers and the importance of building up suitable infrastructure for research to meet increasing demands and competence. The place of partnerships South-South, South-North and networking has been stressed. Finally, the paper calls for greater involvement by policy makers in developing countries in the entire capacity building process. They should set highly focussed research priorities, identify competence not already existing and proceed to fill these gaps along the lines described.

Decision Making, Organizational↗

Desiderata for product labeling of medical expert systems.

The proliferation and increasing complexity of medical expert systems raise ethical and legal concerns about the ability of practitioners to protect their patients from defective or misused software. Appropriate product labeling of expert systems can help clinical users to understand software indications and limitations. Mechanisms of action and knowledge representation schema should be explained in layperson's terminology. User qualifications and resources available for acquiring the skills necessary to understand and critique the system output should be listed. The processes used for building and maintaining the system's knowledge base are key determinants of the product's quality, and should be carefully documented. To meet these desiderata, a printed label is insufficient. The authors suggest a new, more active, model of product labeling for medical expert systems that involves embedding 'knowledge of the knowledge base', creating user-specific data, and sharing global information using the Internet.

Artificial Intelligence↗

Using description logic to manage question corpora.

If clinical questions are to be used on a large scale as a practitioner interface to the medical knowledge base, improved methods must be developed for the semantic management of question corpora. In this project we investigate the use of description logic to manage question corpora. We propose the addition of a Q-box to a standard Description Logic knowledge base. The Q-box will contain concept descriptions that are not yet accepted as part of the T-box, but in effect represent questions about concepts already described in the T-box.

Information Storage and Retrieval↗

A strategy for developing practice guidelines for the ICU using automated knowledge acquisition techniques.

OBJECTIVES: To implement practice guideline entry tools in a reminder system in order to provide decision support to health care workers in clinical care and emergency care environments. To design a knowledge acquisition environment that enables physicians to formulate, update, and verify guidelines without the assistance of a knowledge engineer. METHODS: We developed a knowledge acquisition environment for the Intensive Care Unit (ICU) consisting of 1) a graphical knowledge acquisition tool, 2) tools that perform logical and semantic tests on proposed guidelines, 3) a Patient Data Management System (PDMS) containing clinical patient data, and 4) an expert system that reminds ICU health care workers of inconsistencies between a treatment plan and implemented guidelines. Physicians enter the guidelines using the knowledge acquisition tool, after which consistency and correctness tests are performed on the guidelines. The guidelines are then transferred to the knowledge base of the reminder system and validated by applying the new guidelines to a large stored data set of previous patients. If the new guidelines are approved, they are exported to the reminder system that is used in daily practice. RESULTS: ICU physicians used the knowledge acquisition tool to enter 58 guidelines into the reminder system's knowledge base. These guidelines were tested on a data set consisting of 803 previously admitted patients. As a result, 27 guidelines fired at least once, generating 406 reminders in total. Of the 406 generated reminders, 356 (88%) were issued correctly and 50 (12%) were false alarms. The reminders that were issued correctly involved 3 situations: 1) the database contained inconsistent or incomplete information, 2) the actions or decisions of the health care workers were not the most appropriate ones, and 3) there was a potential risk involved. All false alarms were caused by the fact that the corresponding guidelines were not specific enough to handle certain exceptions. As a result of this analysis, the guidelines could be improved in such a way as to eliminate all false alarms. CONCLUSIONS: These first results demonstrate that this bottom-up knowledge acquisition strategy, implemented by the automated knowledge acquisition tools, enables medical specialists to improve the quality of computer support in an ICU without assistance of a knowledge engineer.

Artificial Intelligence↗

A performance evaluation of the expert system ANEMIA.

This paper reports the results of an evaluation study of the current level of performance given by ANEMIA, a knowledge-based consultation system addressing the clinical problem of managing anemic patients. ANEMIA was developed on a mainframe using the AI programming scheme EXPERT and then translated into a version running on a personal computer. At present the system is able to provide assistance in the diagnosis and management of 65 disease entities. After extensive local testing of accuracy, completeness, and consistency of the knowledge base included into ANEMIA, we designed a study to evaluate whether the system is able to appropriately mirror also the reasoning of well-known hematologists other than those who provided the knowledge. We were also interested in testing whether there were conflicting opinions among hematologists. Thus, we designed a validation study in which ANEMIA's performance could be compared with that of six hematologists and the interexpert consensus evaluated. ANEMIA's overall performance was judged acceptable in 87% (26/30) of the cases, while expert evaluators agreed with their colleagues in 90% (27/30) of them. A low interexpert consensus was found: considering the ratings given by different hematologists to the same ANEMIA performance, complete agreement occurred only 47% of the time.

Adult↗

The educational preparation of undergraduate nursing students in pharmacology: a survey of lecturers' perceptions and experiences.

BACKGROUND: Nurses have key responsibilities in the administration and management of medication therapy and client education. It is of some concern therefore that the literature indicates that nurses are inadequately prepared in this area. AIMS: This paper explores the perceptions and expectations of lecturers about teaching and learning pharmacology in preregistration nursing courses. RESEARCH METHODS: Questionnaires were distributed to lecturers involved in teaching pharmacology to undergraduate nursing students during 2000. The questionnaire was distributed to all university campuses (n = 13) in Victoria, Australia, that are involved in undergraduate nursing education. The questionnaire was an adaptation of the survey instrument used in the Nursing and Medication Education [NAME] project and examined in this questionnaire: the integration of pharmacology teaching into nursing, range and depth of classroom-based pharmacology teaching, approaches to teaching and learning, nursing practice in a clinical context, related importance of patient education and communication skills, and the appropriate professional background of academics teaching pharmacology to preregistration nursing students. RESULTS: There was great variation between institutions as to the number of hours devoted to pharmacology and when it was offered. A number of respondents indicated that they were dissatisfied with the preparation of graduates and their knowledge base in pharmacology. LIMITATIONS: The study was limited by a low response rate of 34%. CONCLUSIONS: A review of nursing curricula is required to improve the knowledge base of nurses in pharmacology and to facilitate their skills in life-long learning.

Attitude of Health Personnel↗

Electronic health record meets digital library: a new environment for achieving an old goal.

Linking the electronic health record to the digital library is a Web-era reformulation of the long-standing informatics goal of seamless integration of automated clinical data and relevant knowledge-based information to support informed decisions. The spread of the Internet, the development of the World Wide Web, and converging format standards for electronic health data and digital publications make effective linking increasingly feasible. Some existing systems link electronic health data and knowledge-based information in limited settings or limited ways. Yet many challenging informatics research problems remain to be solved before flexible and seamless linking becomes a reality and before systems become capable of delivering the specific piece of information needed at the time and place a decision must be made. Connecting the electronic health record to the digital library also requires positive resolution of important policy issues, including health data privacy, government encouragement of high-speed communications, electronic intellectual property rights, and standards for health data and for digital libraries. Both the research problems and the policy issues should be important priorities for the field of medical informatics.

Internet↗

How much effort is needed to keep up with the literature relevant for primary care?

OBJECTIVES: Medicine must keep current with the research literature, and keeping current requires continuously updating the clinical knowledge base (i.e., references that provide answers to clinical questions). The authors estimated the volume of medical literature potentially relevant to primary care published in a month and the time required for physicians trained in medical epidemiology to evaluate it for updating a clinical knowledge base. METHODS: We included journals listed in five primary care journal review services (ACP Journal Club, DynaMed, Evidence-Based Practice, Journal Watch, and QuickScan Reviews). Finding little overlap, we added the 2001 "Brandon/Hill Selected List of Print Books and Journals for the Small Medical Library." We counted articles (including letters, editorials, and other commentaries) published in March 2002, using bibliographic software where possible and hand counting when necessary. For journals not published in March 2002, we reviewed the nearest issue. Five primary care physicians independently evaluated fifty randomly selected articles and timed the process. RESULTS: The combined list contained 341 currently active journals with 8,265 articles. Adjusting for publication frequency, we estimate 7,287 articles are published monthly in this set of journals. Physicians trained in epidemiology would take an estimated 627.5 hours per month to evaluate these articles. CONCLUSIONS: To provide practicing clinicians with the best current evidence, more comprehensive and systematic literature surveillance efforts are needed.

Clinical Competence↗

Decision support for drug prescription integrated with computer-based patient records in primary care.

A conceptual model of an information system that integrates a controlled vocabulary, a patient database, and a knowledge base is described. Methods, design and components for the implementation of the system are discussed. It is argued that the key issue for the successful introduction of computer-based decision support in primary care today is integration with a computer-based patient record. Also important is that the knowledge acquisition process is based on the general practitioner's real needs. This has been achieved by, first, providing general practitioners with real patient data from a series of retrospective database studies; and second, letting a panel of general practitioners select, discuss and decide which computer reminders to implement. A hybrid representation scheme was chosen for the knowledge base. The combination of a standard procedural representation (the so-called Arden syntax) for the reminder knowledge with a semantic net representation for the medical factual knowledge facilitates knowledge sharing with other systems and knowledge reuse within the system.

Artificial Intelligence↗

An integrative model for in-silico clinical-genomics discovery science.

Human Genome discovery research has set the pace for Post-Genomic Discovery Research. While post-genomic fields focused at the molecular level are intensively pursued, little effort is being deployed in the later stages of molecular medicine discovery research, such as clinical-genomics. The objective of this study is to demonstrate the relevance and significance of integrating mainstream clinical informatics decision support systems to current bioinformatics genomic discovery science. This paper is a feasibility study of an original model enabling novel "in-silico" clinical-genomic discovery science and that demonstrates its feasibility. This model is designed to mediate queries among clinical and genomic knowledge bases with relevant bioinformatic analytic tools (e.g. gene clustering). Briefly, trait-disease-gene relationships were successfully illustrated using QMR, OMIM, SNOMED-RT, GeneCluster and TreeView. The analyses were visualized as two-dimensional dendrograms of clinical observations clustered around genes. To our knowledge, this is the first study using knowledge bases of clinical decision support systems for genomic discovery. Although this study is a proof of principle, it provides a framework for the development of clinical decision-support-system driven, high-throughput clinical-genomic technologies which could potentially unveil significant high-level functions of genes.

Artificial Intelligence↗

Supporting families: how are nursing students being prepared for this developing role across Scotland.

Increasing emphasis on primary care has led to a reappraisal of the scope and importance of nursing work with families. The purpose of this study was to explore the knowledge base of lecturers in Scotland that underpinned instruction of student nurses in working with families at diploma and undergraduate level. A postal survey was conducted throughout the 11 educational institutions providing pre-registration nursing programmes. Data were collected from a purposive sample and quantitatively analysed using descriptive statistics. Qualitative data were subjected to content analysis. The response rate was 54.7% (n=95). Findings showed a consensus about the importance of nursing work with families. Family nursing was seen to be relevant across all branches of nursing and academic programmes. There was no statistically significant difference between the levels of academic qualification and perceived knowledge base of lecturers with reference to family nursing theory. The need for a conceptual framework for family nursing was suggested. Knowledge of family nursing literature was limited and necessity for professional development in the teaching of family nursing was acknowledged. The implications of the inquiry point to the need for the integration of family nursing into nursing curricula in Scotland.

Attitude↗

Reforming teacher education: a model program for preparing teachers of deaf children.

Recent literature is replete with the concerns of general educators that students majoring in elementary and pre-primary education do not acquire sufficient content and liberal arts matter as a part of their knowledge base. Educators in undergraduate teacher preparation programs in deafness have expressed the same concerns. This article describes how the Program in Education of Deaf Children at the University of North Carolina at Greensboro added courses in a second major and in liberal arts to expand the knowledge base of prospective teachers of deaf and hard of hearing children.

Adolescent↗

Nutrition knowledge of nurses in long-term care facilities.

BACKGROUND: The purpose of this study was to determine knowledge-based nutrition competencies of nurses and describe needed nutrition education relative to reducing protein-calorie malnutrition (PCM) in nursing home residents. METHOD: A sample of 44 nurses (35 RNs, 9 LPNs) from five eastern Washington nursing homes completed a 50-item questionnaire that measured nutrition knowledge based on Benner's Novice to Expert Model. RESULTS: Nurses scored an average 65% +/- 11% on the nutrition examination. CONCLUSION: An educational program addressing the identified deficient areas could improve the ability of nursing staff to assess and monitor resident food intake, thereby reducing the prevalence of PCM of residents in nursing homes.

Aged↗

Large-scale protein modelling and integration with the SWISS-PROT and SWISS-2DPAGE databases: the example of Escherichia coli.

Knowledge-based molecular modelling of proteins has proven useful in many instances, including the rational design of mutagenesis experiments, but it has generally been limited by the availability of expensive computer hardware and software. To overcome these limitations, we developed the SWISS-MODEL server for automated knowledge-based protein modelling. The SWISS-MODEL server uses the Brookhaven Protein Data Bank as a source of structural information and automatically generates protein models for sequences which share significant similarities with at least one protein of known three-dimensional structure. We have now used the software framework of the server to generate large collections of protein models, and established the SWISS-MODEL Repository, a new database for automatically generated and theoretical protein models. This repository is directly integrated with the SWISS-PROT and SWISS-2DPAGE databases through the ExPASy World Wide Web server (URL is http://expasy.hcuge.ch). Here we present an illustration of this process by an application to the Escherichia coli sequences.

Bacterial Proteins↗

Text structures in medical text processing: empirical evidence and a text understanding prototype.

We consider the role of textual structures in medical texts. In particular, we examine the impact the lacking recognition of text phenomena has on the validity of medical knowledge bases fed by a natural language understanding front-end. First, we review the results from an empirical study on a sample of medical texts considering, in various forms of local coherence phenomena (anaphora and textual ellipses). We then discuss the representation bias emerging in the text knowledge base that is likely to occur when these phenomena are not dealt with--mainly the emergence of referentially incoherent and invalid representations. We then turn to a medical text understanding system designed to account for local text coherence.

Hospital Information Systems↗

[Outcomes of nursing education. Retrospective evaluation after five years in working life].

The purpose of the study was to evaluate the quality of outcomes of nursing education. The evaluation takes place five years after the graduation and it allows to evaluate the outcomes from the perspective on nursing practice and to identify the discrepancies between education and working life. This kind of evaluation is very rare in nursing. The data were collected in 1996 by postal questionnaires. The questionnaire was divided into following areas: 1) theoretical knowledge base, 2) interactive skills, 3) educational skills, 4) practical nursing skills and 5) collaborative skills. The sample consisted of graduating nursing students in Finland 1990 (altogether 522). The response rate was 68% (n = 354). The analysis was done statistically. According the results the respondents had the best skills in practical nursing skills, in collaboration and in theoretical knowledge base. The worst skills they had in interactive skills, especially with patients having abuse problems and in educational skills. The results indicate the problems and advantages of existing education and give basis for development.

Clinical Competence↗

The musculoskeletal pain literacy questionnaire (MSK-PLq) - Part 1: Development of a preliminary version through a systematic review and Delphi consensus.

OBJECTIVE: Chronic musculoskeletal (MSK) pain is a leading cause of disability worldwide, and self-management is a first-line approach recommended by international clinical guidelines. Access to evidence-based information that enhances health literacy may support patients' engagement in their self-management and treatment decision-making, potentially reducing disease burden and pain. However, no tool currently exists to assess health literacy specifically in MSK pain. This study aimed to develop and describe the preliminary version of a knowledge-based questionnaire to evaluate MSK pain literacy, the Musculoskeletal Pain-Literacy questionnaire (MSK-PLq). METHODS: A systematic literature review identified existing health literacy instruments and generated a preliminary list of domains. A two-round Delphi study with 22 panellists (19 experts and three people living with chronic MSK pain), followed by consensus meetings, was used to refine domains and items (≥70% agreement). Readability was assessed using the Flesch Reading Ease (FRE) score and three stakeholders were consulted to review the questionnaire for comprehensibility, clarity, and face validity. RESULTS: Six domains were retained (Understand, Access, Appraise, Apply, Digital, Beliefs), comprising 20 items in the preliminary version of MSK-PLq. Readability was acceptable (mean FRE 74, indicating fairly easy reading), and subject feedback supported the questionnaire's clarity and face validity. CONCLUSIONS: The preliminary version of the MSK-PLq is proposed as the first knowledge-based tool to assess functional, interactive, and critical aspects of MSK pain literacy. It may have applications in clinical practice, research, education, and digital health, by informing tailored patient education and supporting self-management strategies, although further psychometric validation is required.

Humans↗