Search

Objectives: To compare the mean per-episode unit cost for a direct-to-consumer (DTC) telemedicine service for medical center employees (OnDemand) with that of in-person care and to estimate whether the offered service increased the use of care., Study Design: Propensity score-matched retrospective cohort study of adult employees and dependents of a large academic health system between July 7, 2017, and December 31, 2019., Methods: To estimate differences in per-episode unit costs within 7 days, we compared costs between OnDemand encounters and conventional in-person encounters (primary care, urgent care, and emergency department) for any similar condition using a generalized linear model. We used interrupted time series analyses limited to the top 10 clinical conditions managed by OnDemand to estimate the effect of OnDemand's availability on the trends for overall employee per-month encounters., Results: A total of 10,826 encounters among 7793 beneficiaries were included (mean [SD] age, 38.5 [10.9] years; 81.6% were women). The mean (SE) 7-day per-episode cost among employees and beneficiaries was lower for OnDemand encounters at $379.76 ($19.83) relative to non-OnDemand encounters at $493.49 ($25.53), a mean per-episode savings of $113.73 (95% CI, $50.36-$177.10; P < .001). After the introduction of OnDemand, among employees with encounters for the top 10 clinical conditions managed by OnDemand, the trend for encounter rates per 100 employees per month increased marginally (0.03; 95% CI, 0.00-0.05; P = .03)., Conclusions: These results suggest that DTC telemedicine staffed by an academic health system and offered directly to employees reduced the per-episode unit costs and only marginally increased utilization, suggesting lower cost overall.

Expansive growth in the use of health information technology (HIT) has dramatically altered medicine without translating to fully realized improvements in healthcare delivery. Bridging this divide will require healthcare professionals with all levels of expertise in clinical informatics. However, due to scarce opportunities for exposure and training in informatics, medical students remain an underdeveloped source of potential informaticists. To address this gap, our institution developed and implemented a 5-tiered clinical informatics curriculum at the undergraduate medical education level: (1) a practical orientation to HIT for rising clerkship students; (2) an elective for junior students; (3) an elective for senior students; (4) a longitudinal area of concentration; and (5) a yearlong predoctoral fellowship in operational informatics at the health system level. Most students found these offerings valuable for their training and professional development. We share lessons and recommendations for medical schools and health systems looking to implement similar opportunities., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Our study addresses the gaps in knowledge of the characterizations of operations by remote tele-critical care medicine (tele-CCM) service providers interacting with the bedside team. The duration of engagements, the evolution of the tele-CCM service over time, and the distress during interactions with the bedside team have not been characterized systematically. These characteristics are critical for planning the deployment of teleICU services and preventing burnout among remote teleICU providers., Methods: REDCap self-reported activity logs collected engagement duration, triggers ( emergency button, tele-CCM software platform, autonomous algorithm, asymmetrical communication platform, phone ), expediency, nature ( proactive rounding, predetermined task, response to medical needs) , communication modes, and acceptance. Seven hospitals with 16 ICUs were overseen between 9/2020 and 9/2021 by teams consisting of telemedicine medical doctors (eMD), telemedicine registered nurses (eRN), and telemedicine respiratory therapists (eRT)., Results: 39,915 total engagements were registered. eMDs had a significantly higher percentage of emergent and urgent engagements (31.9%) vs. eRN (9.8%) or eRT (1.7%). The average tele-CCM intervention took 16.1 ± 10.39 min for eMD, 18.1 ± 16.23 for eRN, and 8.2 ± 4.98 min for eRT, significantly varied between engagement, and expediency, hospitals, and ICUs types. During the observation period, there was a shift in intervention triggers with an increase in autonomous algorithmic ARDS detection concomitant with predominant utilization of asynchronous communication, phone engagements, and the tele-CCM module of electronic medical records at the expense of the share of proactive rounding . eRT communicated more frequently with bedside staff (% MD = 37.8%; % RN = 36.8, % RT = 49.0%) but mostly with other eRTs. In contrast, the eMD communicated with all ICU stakeholders while the eRN communicated chiefly with other RN and house staff at the patient's bedside. The rate of distress reported by tele-CCM staff was 2% among all interactions, with the entity hospital being the dominant factor., Conclusions: Delivery of tele-CCM services has to be tailored to the specific beneficiary of tele-CCM services to optimize care delivery and minimize distress. In addition, the duration of the average intervention must be considered while creating an efficient workflow., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Laudanski, Huffenberger, Scott, Williams, Wain, Jablonski and Hanson.)

Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (n routine  = 109 (53.4%); n urgent  = 82 (40.2%); n emergent  = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly., (© 2022. The Author(s).)

Both provider- and protocol-driven electrolyte replacement have been linked to the over-prescription of ubiquitous electrolytes. Here, we describe the development and retrospective validation of a data-driven clinical decision support tool that uses reinforcement learning (RL) algorithms to recommend patient-tailored electrolyte replacement policies for ICU patients. We used electronic health records (EHR) data that originated from two institutions (UPHS; MIMIC-IV). The tool uses a set of patient characteristics, such as their physiological and pharmacological state, a pre-defined set of possible repletion actions, and a set of clinical goals to present clinicians with a recommendation for the route and dose of an electrolyte. RL-driven electrolyte repletion substantially reduces the frequency of magnesium and potassium replacements (up to 60%), adjusts the timing of interventions in all three electrolytes considered (potassium, magnesium, and phosphate), and shifts them towards orally administered repletion over intravenous replacement. This shift in recommended treatment limits risk of the potentially harmful effects of over-repletion and implies monetary savings. Overall, the RL-driven electrolyte repletion recommendations reduce excess electrolyte replacements and improve the safety, precision, efficacy, and cost of each electrolyte repletion event, while showing robust performance across patient cohorts and hospital systems.

A 24/7 telemedicine respiratory therapist (eRT) service was set up as part of the established University of Pennsylvania teleICU (PENN E-LERT ® ) service during the COVID-19 pandemic, serving five hospitals and 320 critical care beds to deliver effective remote care in lieu of a unit-based RT. The eRT interventions were components of an evidence-based care bundle and included ventilator liberation protocols, low tidal volume protocols, tube patency, and an extubation checklist. In addition, the proactive rounding of patients, including ventilator checks, was included. A standardized data collection sheet was used to facilitate the review of medical records, direct audio-visual inspection, or direct interactions with staff. In May 2020, a total of 1548 interventions took place, 93.86% of which were coded as "routine" based on established workflows, 4.71% as "urgent", 0.26% "emergent", and 1.17% were missing descriptors. Based on the number of coded interventions, we tracked the number of COVID-19 patients in the system. The average intervention took 6.1 ± 3.79 min. In 16% of all the interactions, no communication with the bedside team took place. The eRT connected with the in-house respiratory therapist (RT) in 66.6% of all the interventions, followed by house staff (9.8%), advanced practice providers (APP; 2.8%), and RN (2.6%). Most of the interaction took place over the telephone (88%), secure text message (16%), or audio-video telemedicine ICU platform (1.7%). A total of 5115 minutes were spent on tasks that a bedside clinician would have otherwise executed, reducing their exposure to COVID-19. The eRT service was instrumental in several emergent and urgent critical interventions. This study shows that an eRT service can support the bedside RT providers, effectively monitor best practice bundles, and carry out patient-ventilator assessments. It was effective in certain emergent situations and reduced the exposure of RTs to COVID-19. We plan to continue the service as part of an integrated RT service and hope to provide a framework for developing similar services in other facilities.

Background: Clinical workflows require the ability to synthesize and act on existing and emerging patient information. While offering multiple benefits, in many circumstances electronic health records (EHRs) do not adequately support these needs., Objectives: We sought to design, build, and implement an EHR-connected rounding and handoff tool with real-time data that supports care plan organization and team-based care. This article first describes our process, from ideation and development through implementation; and second, the research findings of objective use, efficacy, and efficiency, along with qualitative assessments of user experience., Methods: Guided by user-centered design and Agile development methodologies, our interdisciplinary team designed and built Carelign as a responsive web application, accessible from any mobile or desktop device, that gathers and integrates data from a health care institution's information systems. Implementation and iterative improvements spanned January to July 2016. We assessed acceptance via usage metrics, user observations, time-motion studies, and user surveys., Results: By July 2016, Carelign was implemented on 152 of 169 total inpatient services across three hospitals staffing 1,616 hospital beds. Acceptance was near-immediate: in July 2016, 3,275 average unique weekly users generated 26,981 average weekly access sessions; these metrics remained steady over the following 4 years. In 2016 and 2018 surveys, users positively rated Carelign's workflow integration, support of clinical activities, and overall impact on work life., Conclusion: User-focused design, multidisciplinary development teams, and rapid iteration enabled creation, adoption, and sustained use of a patient-centered digital workflow tool that supports diverse users' and teams' evolving care plan organization needs., Competing Interests: The application described in this manuscript was designed, developed, and implemented by an internal group of clinicians and clinical application developers at Penn Medicine. There were no outside funds used to design, build, implement, or study the application as described in this manuscript. In 2018—after the design, development, and implementation of this application described in the manuscript—the project leader and the last author of the paper, Dr. Subha Airan-Javia, and the Penn Center for Innovation launched a start-up company to bring the application into other health systems (TrekIT Health Inc. d/b/a CareAlign). Both Dr. Airan-Javia and the Board of Trustees of the University of Pennsylvania own equity in the company and receive royalty payments on an annual basis from sales of the company. Dr. Airan-Javia is a full-time salaried employee and CEO of the company, as well as a member of the Board of Directors. No other authors have any involvement in this company, financial or otherwise. The other authors declare that they have no conflicts of interest related to this work. Dr. Airan-Javia reports no salary from TrekIT Health Inc. during the conduct of the study; but as stated above, has received salary from TrekIT Health Inc. outside the submitted work., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Biosensors represent one of the numerous promising technologies envisioned to extend healthcare delivery. In perioperative care, the healthcare delivery system can use biosensors to remotely supervise patients who would otherwise be admitted to a hospital. This novel technology has gained a foothold in healthcare with significant acceleration due to the COVID-19 pandemic. However, few studies have attempted to narrate, or systematically analyze, the process of their implementation. We performed an observational study of biosensor implementation. The data accuracy provided by the commercially available biosensors was compared to those offered by standard clinical monitoring on patients admitted to the intensive care unit/perioperative unit. Surveys were also conducted to examine the acceptance of technology by patients and medical staff. We demonstrated a significant difference in vital signs between sensors and standard monitoring which was very dependent on the measured variables. Sensors seemed to integrate into the workflow relatively quickly, with almost no reported problems. The acceptance of the biosensors was high by patients and slightly less by nurses directly involved in the patients' care. The staff forecast a broad implementation of biosensors in approximately three to five years, yet are eager to learn more about them. Reliability considerations proved particularly troublesome in our implementation trial. Careful evaluation of sensor readiness is most likely necessary prior to system-wide implementation by each hospital to assess for data accuracy and acceptance by the staff.

The COVID-19 pandemic has accelerated the demand for virtual healthcare delivery and highlighted the scarcity of telehealth medical student curricula, particularly tele-critical care. In partnership with the Penn E-lert program and the Department of Anesthesiology and Critical Care, the Perelman School of Medicine (PSOM) established a tele-ICU rotation to support the care of patients diagnosed with COVID-19 in the Intensive Care Unit (ICU). The four-week course had seven elements: (1) 60 h of clinical engagement; (2) multiple-choice pretest; (3) faculty-supervised, student-led case and topic presentations; (4) faculty-led debriefing sessions; (5) evidence-based-medicine discussion forum; (6) multiple-choice post-test; and (7) final reflection. Five third- and fourth-year medical students completed 300 h of supervised clinical engagement, following 16 patients over three weeks and documenting 70 clinical interventions. Knowledge of critical care and telehealth was demonstrated through improvement between pre-test and post-test scores. Professional development was demonstrated through post-course preceptor and learner feedback. This tele-ICU rotation allowed students to gain telemedicine exposure and participate in the care of COVID patients in a safe environment.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine., Objective: To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic., Design, Setting, and Participants: In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record., Main Outcomes and Measures: A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically., Results: A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties., Conclusions and Relevance: In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

The coronavirus disease 2019 (COVID-19) public health emergency necessitated changes in health care delivery that will have lasting implications. The University of Pennsylvania Health System is a large multihospital system with an academic medical center at its core. To continue to care for patients with and without COVID-19, the system had to rapidly deploy telemedicine. We describe the challenges faced with the existing telemedicine infrastructures, the central mechanisms created to facilitate the necessary conversions, and the workflow changes instituted to support both inpatient and outpatient activities for thousands of providers, many of whom had little or no experience with telemedicine. We also discuss innovations that occurred as a result of this transition and the future of telemedicine at our institution., Competing Interests: S.A. is a member of the EPIC cardiology steering board. The others declared no competing financial interests., (© Lawrence R. Wechsler et al., 2020; Published by Mary Ann Liebert, Inc.)

Background: In hospitals, effective and efficient communication among care providers is critical to the provision of high-quality patient care. Yet, major problems impede communications including the frequent use of interruptive and one-way communication paradigms. This is especially frustrating for frontline providers given the dynamic nature of hospital care teams in an environment that is in constant flux., Methods: We conducted a pre-post evaluation of a commercially available secured messaging mobile application on 4 hospital units at a single institution for over one year. We included care providers on these units: residents, hospitalists, fellows, nurses, social workers, and pharmacists. Utilization metrics and survey responses on clinician perceptions were collected and analyzed using descriptive statistics, the Kruskal-Wallis test, and Mann-Whitney U test where appropriate., Results: Between May 2013 and June 2014, 1,021 providers sent a total of 708,456 messages. About 85.5% of total threads were between two providers and the remaining were group messages. Residents and social workers/clinical resource coordinators were the largest per person users of this communication system, sending 9 (IQR 2-20) and 9 (IQR 2-22) messages per person per day, and receiving 18 (IQR 5-36) and 14 (IQR 5-29) messages per person per day, respectively (p=0.0001). More than half of the messages received by hospitalists, residents, and nurses were read within a minute. Communicating using secured messaging was found to be statistically significantly less disruptive to workflow by both nursing and physician survey respondents (p<0.001 for each comparison)., Conclusions: Routine adoption of secured messaging improved perceived efficiency among providers on 4 hospital units. Our study suggests that a mobile application can improve communication and workflow efficiency among providers in a hospital. New technology has the potential to improve communication among care providers in hospitals., Competing Interests: The authors report no competing financial interests exist, including financial compensation from Cureatr for the use of its system. The views and opinions expressed herein do not reflect those of Cureatr or its affiliates, and no Cureatr official has contributed to the conceptualization or content of this manuscript. The authors report no conflict of interests in the research.

Background: Changes in the medium of communication from paging to mobile secure text messaging may change clinical care, but the effects of these changes on patient outcomes have not been well examined., Objective: To evaluate the association between inpatient medicine service adoption of mobile secure text messaging and patient length of stay and readmissions., Design: Observational study., Participants: Patients admitted to medicine services at the Hospital of the University of Pennsylvania (intervention site; n = 8995 admissions of 6484 patients) and Penn Presbyterian Medical Center (control site; n = 6799 admissions of 4977 patients) between May 1, 2012, and April 30, 2014., Intervention: Mobile secure text messaging., Main Measures: Change in length of stay and 30-day readmissions, comparing patients at the intervention site to the control site before (May 1, 2012 to April 30, 2013) and after (May 1, 2013 to April 30, 2014) the intervention, adjusting for time trends and patient demographics, comorbidities, insurance, and disposition., Key Results: During the pre-intervention period, the mean length of stay ranged from 4.0 to 5.0 days at the control site and from 5.2 to 6.7 days at the intervention site, but trends were similar. In the first month after the intervention, the mean length of stay was unchanged at the control site (4.7 to 4.7 days) but declined at the intervention site (6.0 to 5.4 days). Trends were mostly similar during the rest of the post-intervention period, ranging from 4.4 to 5.6 days at the control site and from 5.4 to 6.5 days at the intervention site. Readmission rates varied significantly within sites before and after the intervention, but overall trends were similar. In adjusted analyses, there was a significant decrease in length of stay for the intervention site relative to the control site during the post-intervention period compared to the pre-intervention period (-0.77 days ; 95 % CI, -1.14, -0.40; P < 0.001). There was no significant difference in the odds of readmission (OR, 0.97; 95 % CI: 0.81, 1.17; P = 0.77). These findings were supported by multiple sensitivity analyses., Conclusions: Compared to a control group over time, hospitalized medical patients on inpatient services whose care providers and staff were offered mobile secure text messaging showed a relative decrease in length of stay and no change in readmissions.

Objectives: This study explored what smartphone health applications (apps) are used by patients, how they learn about health apps, and how information about health apps is shared., Methods: Patients seeking care in an academic ED were surveyed about the following regarding their health apps: use, knowledge, sharing, and desired app features. Demographics and health information were characterized by summary statistics., Results: Of 300 participants, 212 (71%) owned smartphones, 201 (95%) had apps, and 94 (44%) had health apps. The most frequently downloaded health apps categories were exercise 46 (49%), brain teasers 30 (32%), and diet 23 (24%). The frequency of use of apps varied as six (6%) of health apps were downloaded but never used, 37 (39%) apps were used only a few times, and 40 (43%) health apps were used once per month. Only five apps (2%) were suggested to participants by health care providers, and many participants used health apps intermittently (55% of apps ≤ once a month). Participants indicated sharing information from 64 (59%) health apps, mostly within social networks (27 apps, 29%) and less often with health care providers (16 apps, 17%)., Conclusions: While mobile health has experienced tremendous growth over the past few years, use of health apps among our sample was low. The most commonly used apps were those that had broad functionality, while the most frequently used health apps encompassed the topics of exercise, diet, and brain teasers. While participants most often shared information about health apps within their social networks, information was less frequently shared with providers, and physician recommendation played a small role in influencing patient use of health apps., (© 2015 by the Society for Academic Emergency Medicine.)

Objectives: Voluntary patient uptake and use of electronic health record (EHR) features have been low. It is unknown whether EHRs fully meet needs of providers or patients with chronic diseases., Study Design: To explore in-depth user experiences, we conducted 6 focus groups: 3 of patients followed by 3 of providers discussing 2 key EHR components: the after-visit summary (AVS) and the patient portal (PP). Focus groups were audio-recorded, transcribed, and analyzed by 3 independent coders., Methods: Participants with moderate-to-severe asthma and prevalent comorbidities were recruited from 4 primary care and 2 asthma clinics serving low-income urban neighborhoods. Participants discussed their expectations and experience using the AVS and PP, and responded to prototype formats of these features. Additionally, one-on-one interviews were conducted with 10 patients without PP experience to assess their ability to use the system., Results: The 21 patient and 13 provider perspectives differed regarding AVS features and use. Patients wanted a unified view of their medical issues and health management tools, while providers wanted to focus on recommendations from 1 visit at a time. Both groups advocated improving the AVS format and content. Lack of awareness and knowledge about the PP was patients' largest barrier, and was traced back to providers' lack of PP training., Conclusions: Our results underscore the importance of user-centered design when constructing the content and features of the EHR. As technology evolves, an ongoing understanding of patient and provider experiences will be critical to improve uptake, increase use, and ensure engagement, optimizing the potential of EHRs.

Background: On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 M(w) earthquake struck Haiti. The global humanitarian attempt to respond was swift, but poor infrastructure and emergency preparedness limited many efforts. Rapid, successful deployment of emergency medical care teams was accomplished by organizations with experience in mass disaster casualty response. Well-intentioned, but unprepared, medical teams also responded. In this report, we describe the preparation and planning process used at an academic university department of anesthesiology with no preexisting international disaster response program, after a call from an American-based nongovernmental organization operating in Haiti requested medical support. The focus of this article is the pre-deployment readiness process, and is not a post-deployment report describing the medical care provided in Haiti., Methods: A real-time qualitative assessment and systematic review of the Hospital of the University of Pennsylvania's communications and actions relevant to the Haiti earthquake were performed. Team meetings, conference calls, and electronic mail communication pertaining to planning, decision support, equipment procurement, and actions and steps up to the day of deployment were reviewed and abstracted. Timing of key events was compiled and a response timeline for this process was developed. Interviews with returning anesthesiology members were conducted., Results: Four days after the Haiti earthquake, Partners in Health, a nonprofit, nongovernmental organization based in Boston, Massachusetts, with >20 years of experience providing medical care in Haiti contacted the University of Pennsylvania Health System to request medical team support. The departments of anesthesiology, surgery, orthopedics, and nursing responded to this request with a volunteer selection process, vaccination program, and systematic development of equipment lists. World Health Organization and Centers for Disease Control guidelines, the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness, published articles, and in-country contacts were used to guide the preparatory process., Conclusion: An organized strategic response to medical needs after an international natural disaster emergency can be accomplished safely and effectively within 6 to 12 days by an academic anesthesiology department, with medical system support, in a center with no previously established response system. The value and timeliness of this response will be determined with further study. Institutions with limited experience in putting an emergency medical team into the field may be able to quickly do so when such efforts are executed in a systematic manner in coordination with a health care organization that already has support infrastructure at the site of the disaster.

Electronic nose technology has been developed over the past 15 years in the field of chemistry as an electronic equivalent of the biologic mechanism of smell. Since its inception, it has been well recognized that there is great potential in applying this technology to the field of medicine. This review discusses those areas of medicine in which electronic nose technology has been applied. For each area, this review addresses the scope of the medical problem that has been studied, how the electronic nose technology may help address the medical problem, and the results of such studies to date. Next generation electronic noses will be refined to better analyze specific disease states. This will require further evaluation of the specific volatiles to be tested. This information may then be brought to bear on refinement of the chemistry of the electronic nose sensors, making them more sensitive and specific for the particular disease of interest. The ultimate goal of work in this arena is to make an electronic nose that is portable, fast, inexpensive and, therefore, suitable for use in the examination room or at the bedside, making it facile as a diagnostic tool.

Unlabelled: The purpose of this study was to determine if rates of telemetry events differ between patients whose monitoring is appropriately "indicated" versus "not indicated" by systematically applying rigorous criteria for appropriateness of electrocardiogram (ECG) telemetry usage. We performed a retrospective cohort study on 1097 telemetry admissions between January 1, 2000 and March 31, 2000. A convenience sample of 218 patients generated 236 telemetry admissions. One-hundred-sixty-two arrhythmic events were detected during 400 "indicated" telemetry days. Nine arrhythmic events were detected during 345 "not indicated" telemetry days. The relative rate for arrhythmic events was significantly different, at P < 0.0001, with the incidence rate ratio of 15 indicating a very large effect size. Consequently, current use of ECG telemetry may not be optimal, and a prospective analysis of the application of rigorous indications for ECG telemetry needs to be undertaken., Implications: The application of standard criteria to electrocardiogram telemetry admissions found that the majority of abnormal heart rhythms were found when patients met appropriate criteria.

Objective: This study tested the hypothesis that nitric oxide or nitric oxide and eptifibatide (Integrilin) reversibly inhibit platelet activation and consumption during cardiopulmonary bypass and rapidly restore platelet numbers and function after bypass., Methods: Nitric oxide, a short-acting, reversible platelet inhibitor, was studied with and without eptifibatide, a short-acting, reversible glycoprotein IIb/IIIa inhibitor, in 21 baboons that underwent 60 minutes of normothermic cardiopulmonary bypass with peripheral cannulas. A control group, a group that received 80 ppm nitric oxide, and a group that received both nitric oxide and eptifibatide were studied. Blood samples were obtained at several time points to determine platelet count, aggregation in response to adenosine diphosphate, and levels of beta-thromboglobulin, prothrombin fragment 1.2, and thrombin-antithrombin complex. Template bleeding times were measured before and at 4 intervals after cardiopulmonary bypass., Results: Both nitric oxide and the combination of the 2 drugs significantly attenuated platelet consumption, improved postbypass function, and reduced plasma beta-thromboglobulin release with respect to values in control animals. Both nitric oxide and the combination restored baseline bleeding times 55 minutes after cardiopulmonary bypass ended. No significant differences between nitric oxide and the combination were found for any measurement., Conclusion: Nitric oxide with or without eptifibatide protects platelets during cardiopulmonary bypass and accelerates restoration of normal bleeding times after operation in a baboon model. Although nitric oxide and eptifibatide reversibly inhibit platelets by different mechanisms, in the absence of a wound no synergistic effect was demonstrated.

Background: The inhalation of nitric oxide (NO) in patients with heart failure decreases pulmonary vascular resistance (PVR) and is associated with an increase in pulmonary artery wedge pressure (PAWP). The mechanism for this effect remains unclear., Methods: In dogs rapid-paced for 8 weeks to induce cardiac dysfunction, we performed left ventricular pressure-volume analysis of unpaced hearts in situ to determine whether during NO inhalation (80 ppm), the mechanism for the rise in PAWP is due to: 1) primary pulmonary vasodilation; 2) a direct negative inotropic effect; or 3) impairment of ventricular relaxation., Results: Inhalation of NO decreased PVR by 51%+/-3.8% (257+/-25 vs 127+/-18 dynes x sec x cm(-5) [NO 80 ppm]; p < 0.001) and increased PAWP (15.4+/-2.4 vs 18.1+/-2.6 mm Hg [NO 80 ppm]; p < 0.001). Calculated systemic vascular resistance remained unchanged. Left ventricular (LV) end-diastolic pressure rose (16.4+/-1.9 vs 19.1+/-1.8 mm Hg [NO 80 ppm]; p < 0.001), as did LV end-diastolic volume (83.5+/-4.0 vs 77.0+/-3.4 mL [NO 80 ppm]; p = 0.006). LV peak +dP/dt was unchanged by NO (1,082+/-105 vs 1,142+/-111 mm Hg/sec [NO 80 ppm]; p = NS). There was a trend toward a stroke volume increase (17.4+/-1.2 vs 18.8+/-1.3 mL; p = NS), but the relaxation time constant and end-diastolic pressure-volume relation were both unchanged., Conclusions: In this canine model of cardiomyopathy, inhaled NO decreases pulmonary vascular resistance. The associated increase in left ventricular filling pressure appears to be secondary to a primary pulmonary vasodilator effect of NO without primary effects on the contractile or relaxation properties of the left ventricle.

When computer-based aids do not support the human users' decision-making strategies or anticipate the organizational impacts of technological change, advances in information technology may degrade rather than enhance decision-making performance. Such failures suggest the design of human-computer cooperation for problem solving and decision-making must be driven by human cognitive and organizational process requirements rather than computer technology. Decision- and user-centered development techniques involve domain experts and end-users in the earliest phases of design to evolve an understanding of requirements through iterative prototyping. This paper presents a collaborative approach to cognitive systems engineering applied to developing a clinical aid to assist respiratory care in the surgical ICU.

Dogs of mixed breed (n = 7) were anesthetized, right lung atelectasis was established, and the cyclooxygenase pathway was blocked with ibuprofen. Measurements of pulmonary gas exchange were performed (fractional concentration of inspired O2 = 0.95) after infusions of prostaglandin F2alpha (PGF2alpha; 2 microg . kg-1 . min-1), ventilation with nitric oxide (NO; 40 ppm), or both (PGF2alpha + NO) in random order. The arterial PO2 (PaO2) under control conditions was 117 +/- 16 Torr (shunt = 33 +/- 2.5%), was unchanged with NO alone (PaO2 = 114 +/- 17 Torr; shunt = 35.7 +/- 3. 1%), but was significantly improved with PGF2alpha alone (PaO2 = 180 +/- 28 Torr; shunt = 23.2 +/- 2.8%) and with the combination of PGF2alpha + NO (PaO2 = 202 +/- 30 Torr; shunt = 20.9 +/- 2.5%). The addition of NO did not significantly enhance the effectiveness of the PGF2alpha on PaO2. Simulation of these data in a computer model, combining pulmonary gas exchange and pulmonary blood flow, reproduced the results on the basis that vasoconstriction with PGF2alpha was maximal under hypoxia in the atelectatic lung and reduced by hyperoxia in the ventilated lung, consistent with the hypothesis of O2 dependence of PGF2alpha vasoconstriction.

Background: Inhaled nitric oxide (NO), a selective vasodilator, improves oxygenation in many patients with adult respiratory distress syndrome (ARDS). Vasoconstrictors may also improve oxygenation, possibly by enhancing hypoxic pulmonary vasoconstriction. This study compared the effects of phenylephrine, NO, and their combination in patients with ARDS., Methods: Twelve patients with ARDS (PaO2/FIO2 180; Murray score 2) were studied. Each patient received three treatments in random order: intravenous phenylephrine, 50-200 micrograms/min, titrated to a 20% increase in mean arterial blood pressure; inhaled NO, 40 ppm; and the combination (phenylephrine+NO). Hemodynamics and blood gas measurements were made during each treatment and at pre- and posttreatment baselines., Results: All three treatments improved PaO2 overall. Six patients were "phenylephrine-responders" (delta PaO2 > 10 mmHg), and six were "phenylephrine-nonresponders." In phenylephrine-responders, the effect of phenylephrine was comparable with that of NO (PaO2 from 105 +/- 14 to 132 +/- 14 mmHg with phenylephrine, and from 110 +/- 14 to 143 +/- 19 mmHg with NO), and the effect of phenylephrine+NO was greater than that of either treatment alone (PaO2 from 123 +/- 13 to 178 +/- 23 mmHg). In phenylephrine-nonresponders, phenylephrine did not affect PaO2, and the effect of phenylephrine+NO was not statistically different from that of NO alone (PaO2 from 82 +/- 12 to 138 +/- 28 mmHg with NO; from 84 +/- 12 to 127 +/- 23 mmHg with phenylephrine+NO). Data are mean +/- SEM., Conclusions: Phenylephrine alone can improve PaO2 in patients with ARDS. In phenylephrine-responsive patients, phenylephrine augments the improvement in PaO2 seen with inhaled NO. These results may reflect selective enhancement of hypoxic pulmonary vasoconstriction by phenylephrine, which complements selective vasodilation by NO.

Tiacumicins B and C are members of a novel group of 18-membered macrolide antibiotics with in vitro activity against Clostridium difficile. The MICs against 15 strains of C. difficile were 0.12 to 0.25 microgram/ml for tiacumicin B, 0.25 to 1 microgram/ml for tiacumicin C, and 0.5 to 1 microgram/ml for vancomycin. The resistance frequency for both compounds against C. difficile was less than 2.8 x 10(-8) at four and eight times the MIC. The in vivo activities of the tiacumicins against two strains of C. difficile were compared with that of vancomycin in a hamster model of antibiotic-associated colitis. Oral therapy with 0.2, 1, or 5 mg of tiacumicin B or C per kg of body weight protected 100% of clindamycin-treated hamsters exposed to C. difficile ATCC 9689. Oral treatment with identical doses of vancomycin produced a prolonged, dose-dependent survival of hamsters, but it did not prevent the development of fatal colitis at doses of up to 5 mg/kg. When clindamycin-treated animals were exposed to another strain of C. difficile, both tiacumicin B and vancomycin were protective at 5 mg/kg, but not at lower doses. Tiacumicin C was not tested in vivo against the second strain of C. difficile. No tiacumicin B or C was detected in the sera of hamsters treated with single oral doses of 25 mg/kg, while antibiotic levels in the ceca of these hamsters reached 248 micrograms/ml and 285 mg/ml for tiacumicins B and C, respectively. The tiacumicins demonstrated in vitro and in vivo potencies against C. difficile and achieved high concentrations in the cecum, but not the serum, of hamsters after oral administration.

The in vitro and in vivo properties of a new 1-difluorophenyl-6-fluoroquinolone, temafloxacin hydrochloride (A-62254), were compared with those of difloxacin and ciprofloxacin. Temafloxacin hydrochloride was as active as ciprofloxacin and difloxacin against staphylococci and as active as ciprofloxacin and 2 twofold dilutions more active than difloxacin against streptococci. Against gram-negative enteric bacteria and Pseudomonas aeruginosa, temafloxacin hydrochloride was 2 twofold dilutions more active than difloxacin but 2 to 4 twofold dilutions less active than ciprofloxacin. The MICs of temafloxacin hydrochloride and difloxacin were increased by 2 to 5 twofold dilutions in urine at pH 6.5 compared with 4 to 5 twofold-dilution increases in the MICs of ciprofloxacin. The MICs of temafloxacin hydrochloride, difloxacin, and ciprofloxacin were increased by 1 to 3 twofold dilutions in serum. The MICs of temafloxacin hydrochloride, difloxacin, and ciprofloxacin were the same or within 1 to 2 twofold dilutions at pHs 6.5, 7.2, and 8.0. When administered orally in mouse protection tests, temafloxacin hydrochloride was as active as difloxacin and 5 to 10 times more active than ciprofloxacin against infections with Staphylococcus aureus and streptococci. Against infections with gram-negative enteric bacteria and P. aeruginosa, temafloxacin hydrochloride was as active as difloxacin and ciprofloxacin. Temafloxacin hydrochloride was three times less active than difloxacin but was five times more active than ciprofloxacin against infections with Salmonella typhimurium. Temafloxacin hydrochloride was as active as difloxacin and ciprofloxacin against P. aeruginosa and Proteus mirabilis pyelonephritis in mice. The peak serum concentration and serum half-life of temafloxacin hydrochloride in mice were approximately one-half and one-sixth, respectively, that of difloxacin after oral administration. The peak serum concentration of temafloxacin hydrochloride in mice after oral administration was six times higher than that of ciprofloxacin, and the serum half-life was equal to that of ciprofloxacin.

The in vitro and in vivo antibacterial activity of A-56268 (TE-031), the 6-O-methyl derivative of erythromycin, was compared with those of erythromycin and other reference drugs. A-56268 had the same spectrum of antibacterial activity as erythromycin. A-56268 was generally 1 log2 dilution more potent or equal to erythromycin against all organisms except haemophilus influenzae and Propionibacterium acnes, for which A-56268 was 1 log2 dilution and 3 log2 dilutions, respectively, less potent. The MBC of A-56268 and erythromycin was not significantly different from the MIC against Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus epidermidis, and H. influenzae but was more than 2 log2 dilutions higher than the MICs for some Staphylococcus aureus strains. Human serum at a concentration of 50% did not change the in vitro potency of A-56268 or erythromycin. A-56268 was similar to erythromycin in being more active at pH 8.0 than at the physiologic pH of 7.3. The activity of A-56268 was synergistic with sulfamethoxazole against 4 of 12 strains of H. influenzae. In mouse protection tests, when administered orally A-56268 was more potent than erythromycin against H. influenzae, S. pyogenes, S. pneumoniae, and S. aureus. After subcutaneous administration the potencies of A-56268 and erythromycin were not statistically different from each other. A-56268 was more potent than erythromycin against Legionella infection in guinea pigs. The concentration of A-56268 in the serum and lung was higher than that of erythromycin after intraperitoneal administration. In A-56268 in the serum and lung was higher than that of erythromycin after intraperitoneal administration. In mice, the peak levels in serum of A-56268 and erythromycin were similar after subcutaneous administration and seven times higher for A-56268 after oral administration. The serum half-life of A-56268 was approximately twice that of erythromycin after administration by both routes.

By measuring the colony size of a variety of anaerobic bacteria isolated from clinical specimens, an evaluation was made of the benefits derived from the addition of several enrichments to blood agar medium commonly used for the growth of anaerobes. Similar methods were used to study the effects of various storage conditions and age of the medium. The results were compared with those obtained on freshly prepared and enriched blood agar plates as well as commercially available blood agar plates. Freshly prepared and enriched blood agar was found to give substantially larger colonies than could be grown on commercially obtained blood agar plates when both were inoculated and incubated under identical conditions. Storage of plating media under CO2 for periods of up to 72 h had only a minor effect on the growth of the anaerobic bacteria studied, but longer periods of storage under CO2 resulted in a less efficient plating medium. Nonenriched brain heart infusion (BHI) was found to be a better basal medium than Trypticase soy agar (TSA) medium. Colony size on fully enriched BHI blood agar plates was greater than nonenriched BHI greater than nonenriched TSA greater than commercially prepared nonenriched TSA plates. The data suggest that freshness of the plates may be as important as using rich media.

A-61827 (A-60969 is the hydrochloric salt of A-61827) is a new aryl-fluoronaphthyridine which is active against aerobic and anaerobic bacteria. The MICs of A-61827 for 90% of strains (MIC90) of staphylococci and streptococci were less than or equal to 1 microgram/ml and were generally 1 to 4 twofold dilutions less than those of ciprofloxacin for these bacteria. The MIC90S of A-61827 for members of the family Enterobacteriaceae and Pseudomonas aeruginosa were also less than or equal to 1 microgram/ml. Ciprofloxacin was 1 to 3 twofold dilutions more active than A-61827 against these gram-negative bacteria. Neisseria gonorrhoeae, Campylobacter jejuni, and Haemophilus influenzae were susceptible to less than 0.06 microgram of A-61827 per ml. The MIC90 of A-61827 for Legionella pneumophila was 0.25 microgram/ml. A-61827 was as potent or 1 to 2 twofold dilutions more potent than ciprofloxacin against these organisms. The MIC90 of A-61827 for all anaerobic bacteria was less than or equal to 4 micrograms/ml compared with less than or equal to 32 micrograms/ml for ciprofloxacin. In mouse protection tests, A-61827 was as active as ciprofloxacin against Escherichia coli, P. aeruginosa, and Salmonella typhimurium and 5 to 10 times more active than ciprofloxacin against Staphylococcus aureus and Streptococcus pyogenes. A-61827 was as active as ciprofloxacin against P. aeruginosa in a mouse pyelonephritis model and more active than ciprofloxacin and metronidazole in a mouse Bacteroides fragilis abscess model. After oral administration of 100 mg/kg to mice, the peak concentrations of A-61827 and ciprofloxacin in serum were 2.3 and 2.4 micrograms/ml and the half-lives in serum were 3.9 and 1.2 h, respectively.

A microwave oven was used to melt microbiological media, resulting in a substantial reduction of heat generation and considerable savings in time.

There is no effective therapy to treat Mycobacterium avium complex infection in patients with acquired immune deficiency syndrome. Clarithromycin (A-56268; TE-031) is a new macrolide which is twofold more active than erythromycin against most aerobic bacteria. In addition, higher levels in serum and tissue are achieved with clarithromycin than with erythromycin. In this study, clarithromycin, erythromycin, difloxacin, temafloxacin, ciprofloxacin, rifampin, amikacin, and ethambutol were tested in vitro and in vivo against the M. avium complex. The MICs for 90% of strains tested were 4 micrograms/ml for clarithromycin, 64 micrograms/ml for erythromycin, 32 micrograms/ml for difloxacin, 8 micrograms/ml for temafloxacin, 4 micrograms/ml for ciprofloxacin, 4 micrograms/ml for rifampin, 32 micrograms/ml for amikacin, and 32 micrograms/ml for ethambutol. Beige mice were infected intravenously with 10(7) CFU of M. avium ATCC 25291. Treatment was started on day 6 after infection and was administered twice a day at 8-h intervals for 9 days. Clarithromycin was the most effective compound in these tests and was effective in reducing the viable bacterial counts in the spleen when it was administered subcutaneously or orally at a dose of 25 mg/kg. Amikacin was the only other compound which showed activity in vivo. The peak concentration in serum at which clarithromycin was active was approximately 1.0 microgram/ml.

The in vitro antibacterial potencies of A-56619 and A-56620, two new aryl-fluoroquinolones, were compared with the potency of norfloxacin against a broad spectrum of organisms. Cefotaxime, aztreonam, piperacillin, imipenem, penicillin, and gentamicin were also tested for reference purposes. The MICs required to inhibit at least 90% of the strains tested ranged from 0.25 to 4 micrograms/ml for A-56619 and from 0.06 to 0.5 microgram/ml for A-56620 for members of the Enterobacteriaceae. A-56619 was generally twofold less potent and A-56620 was twofold more potent than norfloxacin against most aerobic gram-negative bacilli, including members of the Enterobacteriaceae and Pseudomonas aeruginosa. Against indole-positive Proteus, Morganella, Providencia rettgeri, and Serratia strains, A-56619 was at least 8- to 16-fold less potent than norfloxacin. A-56619 and A-56620 were four- to eightfold more potent than norfloxacin against Staphylococcus aureus and equally potent to fourfold more potent against Streptococcus species, Haemophilus influenzae, and Neisseria gonorrhoeae. The MICs of A-56619 and A-56620 were only slightly affected by increased inoculum size or by the addition of various cations at physiologic concentrations. A-56619 was three- to fivefold less active at pH 8.0 than at pH 6.5 or 7.2. A-56620 was twofold less active at pH 6.5 than at pH 8.0 or 7.2 against members of the Enterobacteriaceae and Pseudomonas aeruginosa; similar pH variations did not affect A-56620 activity against gram-positive cocci. The potencies of A-56619, A-56620, and norfloxacin were less in urine than in Mueller-Hinton broth; however, this effect was more pronounced with norfloxacin. Human serum at a concentration of 50% caused a 4- to 64- fold decrease in the potency of A-56619 and an average 4-fold decrease in the potency of A-56620, compared with no effect on the potency of norfloxacin. A-56619, A-56620, and norfloxacin were bactericidal and, at four times the MIC, reduced the viable cell counts of Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa by approximately 99.9% within 2 h. A-56619, A-56620, and norfloxacin showed no significant synergistic activity and no antagonism when they were aminoglycoside or beta-lactam antimicrobial agents.

A-56268 is a 6-O-methyl derivative of erythromycin A which has a spectrum of activity similar to that of erythromycin and is 1 log2 dilution more potent than erythromycin against most organisms that have been tested. The correlation of zone size diameters and MICs of A-56268 for 461 strains of bacteria isolated from clinical specimens was investigated. Based on anticipated levels in human serum of 2 micrograms/ml, 15-microgram disks have been recommended with zone size standards of greater than or equal to 15 mm for susceptibility (MIC correlate, less than or equal to 2.0 micrograms/ml) and less than or equal to 11 mm for resistance (MIC correlate, greater than or equal to 8 micrograms/ml). Selection of these tentative breakpoints resulted in no very major errors (false susceptible), a major error (false resistant) rate of 0.22%, and an acceptable minor error (intermediate) rate of 2.82%. MIC ranges and zone diameter limits for quality control organisms used in the standardized agar dilution and disk diffusion susceptibility tests with A-56268 are given.

Changes in nucleotide pools and extracellular nucleotides during the developmental cycle of the myxobacterium Myxococcus xanthus were determined using a high-pressure liquid chromatography nucleotide analyzer. A general increase in all nucleotide pools occurred during the morphological phase of glycerol conversion of vegetative cells to myxospores. The levels of the nucleoside triphosphate pools remained high as the myxospore matured and throughout subsequent germination. Oxidized nicotinamide adenine dinucleotide levels were elevated in the dormant myxospore and then declined during germination. The adenylate energy charge value was 0.85 +/- 0.02 for vegetative cells, germinating myxospores, and 6-h-old myxospores. It was interesting that the value for the so-called dormant myxospore was the same as that characteristic of physiologically active cells. The germinating myxospores excreted large quantities of uracil along with lesser quantities of purine nucleoside monophosphates. Although the source of the extracellular uracil cannot be determined from these experiments, it may have been derived from a shift in base ratios accompanying an assumed ribonucleic acid turnover during germination.

A simplified method has been developed for agar dilution antimicrobial susceptibility testing of anaerobic bacteria, designed to economize on time and money when only a few isolates need to be tested. The procedure is based on the principle of using filter paper disks as carriers of the antibiotic and 35- by 10-mm petri dishes which, when inoculated with the Steers replicator, can test up to four organisms per plate. The procedure was run in parallel with conventional agar dilution techniques and showed 95% agreement to within one dilution for all minimal inhibitory concentrations recorded on fresh anaerobic isolates from clinical specimens. The technique was further simplified by using commercially available antibiotic-containing disks, thereby alleviating the tedious and time-consuming procedure of preparing the disks. The data indicated that 48- to 72-h diffusion periods were sufficient to achieve a uniform concentration of the antibiotic in the petri plate and that the antibiotics were stable at room temperature for that period of time. In terms of applicability and relevance to the needs of the clinical microbiology laboratory, the modified agar dilution method for rapid antimicrobial susceptibility testing of individual anaerobic isolates was found to be superior to the broth dilution method since it was easier to read and required considerably less set up time.

With the advent of low-cost modular microcomputer technology, discussions of computer-based instruction (CBI) have taken on a new direction. Earlier efforts at computer-based instruction were successful in the technical area, but the expense of starting and maintaining the programs deterred the widespread application of CBI. The initial low purchase price and minor maintenance expenses of microcomputers have lessened financial concerns about equipment purchases. The smaller size and the capability of the microcomputer have allowed CBI system developers to focus on more specific (rather than monolithic) projects so that the time and the cost for program development have been reduced. Although students have demonstrated high interest in CBI, faculties expressed some reservation about entering the field because of the new technology and the lack of supporting evidence for the value of this teaching modality. The microcomputer may be the answer to the economic and attitudinal deterrents to the success of previous attempts at CBI.

A comparison of the API and Minitek methods of biochemical testing was made on a variety of anaerobic bacteria. Although API and Minitek results were not compared to more standardized or conventional procedures of identification, multiple repeat testing of the two systems was done on routine clinical isolates and known organisms to determine (i) whether the reactions were reliably consistent, (ii) the ease of reading the two systems with respect to the frequency of questionable results, and (iii) the percentage of routine clinical isolates for which each system yielded an identification. The Minitek system gave a much lower incidence of difficult to interpret reactions. The two systems were comparable in terms of reproducibility and capability of yielding an identification of the anaerobic gram-negative bacilli and Clostridium species, but were unsatisfactory for routine use on most of the other anaerobic bacteria isolated.