Toward a cognitive taxonomy of medical errors.

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Influence of temperature of incubation and type of growth medium on pigmentation in Serratia marcescens.

Maximal amounts of prodigiosin were synthesized in either minimal or complete medium after incubation of cultures at 27 C for 7 days. Biosynthesis of prodigiosin began earlier and the range of temperature for formation was greater in complete medium. No prodigiosin was formed in either medium when cultures were incubated at 38 C; however, after a shift to 27 C, pigmentation ensued, provided the period of incubation at 38 C was not longer than 36 hr for minimal medium or 48 hr for complete medium. Washed, nonpigmented cells grown in either medium at 38 C for 72 hr could synthesize prodigiosin when suspended in saline at 27 C when casein hydrolysate was added. These suspensions produced less prodigiosin at a slower rate than did cultures growing in casein hydrolysate at 27 C without prior incubation at 38 C. Optimal concentration of casein hydrolysate for pigment formation by suspensions was 0.4%; optimal temperature was 27 C. Anaerobic incubation, shift back to 38 C, killing cells by heating, or chloramphenicol (25 mug/ml) inhibited pigmentation. Suspensions of washed cells forming pigment reached pH 8.0 to 8.3 rapidly and maintained this pH throughout incubation for 7 days. Measurements of viable count and of protein, plus other data, indicated that cellular multiplication did not occur in suspensions of washed cells during pigment formation. By this procedure utilizing a shift down in temperature, biosynthesis of prodigiosin by washed cells could be separated from multiplication of bacteria.

Next-generation sequencing of HIV-1 RNA genomes: determination of error rates and minimizing artificial recombination.

Next-generation sequencing (NGS) is a valuable tool for the detection and quantification of HIV-1 variants in vivo. However, these technologies require detailed characterization and control of artificially induced errors to be applicable for accurate haplotype reconstruction. To investigate the occurrence of substitutions, insertions, and deletions at the individual steps of RT-PCR and NGS, 454 pyrosequencing was performed on amplified and non-amplified HIV-1 genomes. Artificial recombination was explored by mixing five different HIV-1 clonal strains (5-virus-mix) and applying different RT-PCR conditions followed by 454 pyrosequencing. Error rates ranged from 0.04-0.66% and were similar in amplified and non-amplified samples. Discrepancies were observed between forward and reverse reads, indicating that most errors were introduced during the pyrosequencing step. Using the 5-virus-mix, non-optimized, standard RT-PCR conditions introduced artificial recombinants in a fraction of at least 30% of the reads that subsequently led to an underestimation of true haplotype frequencies. We minimized the fraction of recombinants down to 0.9-2.6% by optimized, artifact-reducing RT-PCR conditions. This approach enabled correct haplotype reconstruction and frequency estimations consistent with reference data obtained by single genome amplification. RT-PCR conditions are crucial for correct frequency estimation and analysis of haplotypes in heterogeneous virus populations. We developed an RT-PCR procedure to generate NGS data useful for reliable haplotype reconstruction and quantification.

What Type of Resources? Household Effects and Female Electoral Participation

Mechanisms behind partner effects are contingent on women's individual resource endowment. While low and medium educated women most strongly profit from higher educational partner resources, i.e. from a compensatory mechanism, the resource “time” seems to particularly confine political involvement of women with both high professional status or no employment.

The effects of type of interval, sensory modality, base duration, and psychophysical task on the discrimination of brief time intervals

The present study was designed to investigate the influences of type of psychophysical task (two-alternative forced-choice [2AFC] and reminder tasks), type of interval (filled vs. empty), sensory modality (auditory vs. visual), and base duration (ranging from 100 through 1,000 ms) on performance on duration discrimination. All of these factors were systematically varied in an experiment comprising 192 participants. This approach allowed for obtaining information not only on the general (main) effect of each factor alone, but also on the functional interplay and mutual interactions of some or all of these factors combined. Temporal sensitivity was markedly higher for auditory than for visual intervals, as well as for the reminder relative to the 2AFC task. With regard to base duration, discrimination performance deteriorated with decreasing base durations for intervals below 400 ms, whereas longer intervals were not affected. No indication emerged that overall performance on duration discrimination was influenced by the type of interval, and only two significant interactions were apparent: Base Duration × Type of Interval and Base Duration × Sensory Modality. With filled intervals, the deteriorating effect of base duration was limited to very brief base durations, not exceeding 100 ms, whereas with empty intervals, temporal discriminability was also affected for the 200-ms base duration. Similarly, the performance decrement observed with visual relative to auditory intervals increased with decreasing base durations. These findings suggest that type of task, sensory modality, and base duration represent largely independent sources of variance for performance on duration discrimination that can be accounted for by distinct nontemporal mechanisms.

More diversity, less tolerance? The effect of type of cultural diversity on the erosion of tolerance in Swiss municipalities

Immigration and the ways in which host societies receive newcomers pose challenges for modern civil societies. This article contributes to the ongoing discussion about how ethnic diversity influences tolerance towards immigrants. Compared to previous studies, we analyse tolerance as a sequential concept in order to uncover the effects of contextual diversity on attitudes towards immigrants and the granting of certain rights to this group. Moreover, we distinguish different shares of ethnic groups based on their ethnic and cultural origins both on the independent and dependent variable. The analysis relies on a subnational survey of sixty municipalities in Switzerland, revealing that only certain ethnic groups are seen as an economic and cultural threat.

The gene for histone RNA hairpin binding protein is located on human chromosome 4 and encodes a novel type of RNA binding protein.

The hairpin structure at the 3' end of animal histone mRNAs controls histone RNA 3' processing, nucleocytoplasmic transport, translation and stability of histone mRNA. Functionally overlapping, if not identical, proteins binding to the histone RNA hairpin have been identified in nuclear and polysomal extracts. Our own results indicated that these hairpin binding proteins (HBPs) bind their target RNA as monomers and that the resulting ribonucleoprotein complexes are extremely stable. These features prompted us to select for HBP-encoding human cDNAs by RNA-mediated three-hybrid selection in Saccharomyces cerevesiae. Whole cell extract from one selected clone contained a Gal4 fusion protein that interacted with histone hairpin RNA in a sequence- and structure-specific manner similar to a fraction enriched for bovine HBP, indicating that the cDNA encoded HBP. DNA sequence analysis revealed that the coding sequence did not contain any known RNA binding motifs. The HBP gene is composed of eight exons covering 19.5 kb on the short arm of chromosome 4. Translation of the HBP open reading frame in vitro produced a 43 kDa protein with RNA binding specificity identical to murine or bovine HBP. In addition, recombinant HBP expressed in S. cerevisiae was functional in histone pre-mRNA processing, confirming that we have indeed identified the human HBP gene.

Observation of a new type of low-frequency waves at comet 67P/Churyumov-Gerasimenko

We report on magnetic field measurements made in the innermost coma of 67P/Churyumov-Gerasimenko in its low-activity state. Quasi-coherent, large-amplitude (δ B/B ~ 1), compressional magnetic field oscillations at ~ 40 mHz dominate the immediate plasma environment of the nucleus. This differs from previously studied cometary interaction regions where waves at the cometary ion gyro-frequencies are the main feature. Thus classical pickup-ion-driven instabilities are unable to explain the observations. We propose a cross-field current instability associated with newborn cometary ion currents as a possible source mechanism.

Risk Factors for Sternal Wound Infection After Open Heart Operations Vary According to Type of Operation

BACKGROUND This study evaluated whether risk factors for sternal wound infections vary with the type of surgical procedure in cardiac operations. METHODS This was a university hospital surveillance study of 3,249 consecutive patients (28% women) from 2006 to 2010 (median age, 69 years [interquartile range, 60 to 76]; median additive European System for Cardiac Operative Risk Evaluation score, 5 [interquartile range, 3 to 8]) after (1) isolated coronary artery bypass grafting (CABG), (2) isolated valve repair or replacement, or (3) combined valve procedures and CABG. All other operations were excluded. Univariate and multivariate binary logistic regression were conducted to identify independent predictors for development of sternal wound infections. RESULTS We detected 122 sternal wound infections (3.8%) in 3,249 patients: 74 of 1,857 patients (4.0%) after CABG, 19 of 799 (2.4%) after valve operations, and 29 of 593 (4.9%) after combined procedures. In CABG patients, bilateral internal thoracic artery harvest, procedural duration exceeding 300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female sex (model 1) were independent predictors for sternal wound infection. A second model (model 2), using the European System for Cardiac Operative Risk Evaluation, revealed bilateral internal thoracic artery harvest, diabetes, obesity, and the second and third quartiles of the European System for Cardiac Operative Risk Evaluation were independent predictors. In valve patients, model 1 showed only revision for bleeding as an independent predictor for sternal infection, and model 2 yielded both revision for bleeding and diabetes. For combined valve and CABG operations, both regression models demonstrated revision for bleeding and duration of operation exceeding 300 minutes were independent predictors for sternal infection. CONCLUSIONS Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, duration of operation) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female sex) are predictive of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Penetrating injuries of the thorax and abdomen: Type of medical-care institution and case fatality

The purpose of this study was to determine, for penetrating injuries (gunshot, stab) of the chest/abdomen, the impact on fatality of treatment in trauma centers and shock trauma units compared with general hospitals. Medical records of all cases of penetrating injury limited to chest/abdomen and admitted to and discharged from 7 study facilities in Baltimore city 1979-1980 (n = 581) were studied: 4 general hospitals (n = 241), 2 area-wide trauma centers (n = 298), and a shock trauma unit (n = 42). Emergency center and transferred cases were not studied. Anatomical injury severity, measured by modified Injury Severity Score (mISS), was a significant prognostic factor for death, as were cardiovascular shock (SBP $\le$ 70), injury type (gunshot vs stab), and ambulance/helicopter (vs other) transport. All deaths occurred in cases with two or more prognostic factors. Unadjusted relative risks of death compared with general hospitals were 4.3 (95% confidence interval = 2.2, 8.4) for shock trauma and 0.8 (0.4, 1.7) for trauma centers. Controlling for prognostic factors by logistic regression resulted in these relative risks: shock trauma 4.0 (0.7, 22.2), and trauma centers 0.8 (0.2, 3.2). Factors significantly associated with increased risk had the following relative risks by multiple logistic regression: SBP $\le$ 70 (RR = 40.7 (11.0, 148.7)), highest mISS (42 (7.7, 227)), gunshot (8.4 (2.1, 32.6)), and ambulance/helicopter transport (17.2 (1.3, 228.1)). Controlling for age, race, and gender did not alter results significantly. Actual deaths compared with deaths predicted from a multivariable model of general-hospital cases showed 3.7 more than predicted deaths in shock trauma (SMR = 1.6 (0.8, 2.9)) and 0.7 more than predicted deaths in area-wide trauma centers (SMR = 1.05 (0.6, 1.7)). Selection bias due to exclusion of transfers and emergency center cases, and residual confounding due to insufficient injury information, may account for persistence of adjusted high case fatality in shock trauma. Studying all cases prospectively, including emergency center and transferred cases, is needed. ^

RELATION OF TYPE OF REPORTED ILLNESSES TO PATTERN OF USE OF THE STUDENT HEALTH CENTER BY THE INTERNATIONAL STUDENTS AT TEXAS SOUTHERN UNIVERSITY, HOUSTON, TEXAS

The state of knowledge on the relation of stress factors, health problems and health service utilization among university students is limited. Special problems of stress exist for the international students due to their having to adjust to a new environment. It is this latter problem area that provides the focus for this study. Recognizing there are special stress factors affecting the international students, it is first necessary to see if the problems of cultural adaptation affect them to any greater degree than American students attending the same university.^ To make the comparison, the study identified a number of health problems of both American and international students and related their frequency to the use of the Student Health Center. The expectation was that there would be an association between the number of health problems and the number of life change events experienced by these students and between the number of health problems and stresses from social factors. It was also expected that the number of health problems would decline with the amount of social support.^ The population chosen were students newly enrolled in Texas Southern University, Houston, Texas in the Fall Semester of 1979. Two groups were selected at random: 126 international and 126 American students. The survey instrument was a self-administered questionnaire. The response rate was 90% (114) for the international and 94% (118) for the American students.^ Data analyses consisted of both descriptive and inferential statistics. Chi-squares and correlation coefficients were the statistics used in comparing the international students and the American students.^ There was a weak association between the number of health problems and the number of life change events, as reported by both the international and the American students. The study failed to show any statistically significant association between the number of stress from social factors and the number of health problems. It also failed to show an association between the number of health problems and the amount of social support. These findings applied to both the international and the American students.^ One unexpected finding was that certain health problems were reported by more American than international students. There were: cough, diarrhea, and trouble in sleeping. Another finding was that those students with health insurance had a higher level of utilization of the Health Center than those without health insurance. More international than American students utilized the Student Health Center.^ In comparing the women students, there was no statistical significant difference in their reported fertility related health problems.^ The investigator recommends that in follow-up studies, instead of grouping all international students together, that they be divided by major nationalities represented in the student body; that is, Iranians, Nigerians and others. ^

Numer and type of seeds introduced by footwear of travelers to Svalbard and germination success in 2008

Expanding visitation to Polar regions combined with climate warming increases the potential for alien species introduction and establishment. We quantified vascular plant propagule pressure associated with different groups of travelers to the high-Arctic archipelago of Svalbard, and evaluated the potential of introduced seeds to germinate under the most favorable average Svalbard soil temperature (10°C). We sampled the footwear of 259 travelers arriving by air to Svalbard during the summer of 2008, recording 1,019 seeds: a mean of 3.9 (±0.8) seeds per traveler. Assuming the seed influx is representative for the whole year, we estimate a yearly seed load of around 270,000 by this vector alone. Seeds of 53 species were identified from 17 families, with Poaceae having both highest diversity and number of seeds. Eight of the families identified are among those most invasive worldwide, while the majority of the species identified were non-native to Svalbard. The number of seeds was highest on footwear that had been used in forested and alpine areas in the 3 months prior to traveling to Svalbard, and increased with the amount of soil affixed to footwear. In total, 26% of the collected seeds germinated under simulated Svalbard conditions. Our results demonstrate high propagule transport through aviation to highly visited cold-climate regions and isolated islands is occurring. Alien species establishment is expected to increase with climate change, particularly in high latitude regions, making the need for regional management considerations a priority.

Occurrence and type of dolomite in ODP Site 124-768 samples (Table 1)

Occurrence of deep-sea dolomites has been reported from numerous settings (for discussion see Lumsden, 1988). Different authors agree that dolomite formation in the pelagic realm is a relatively early diagenetic process (e.g., Jorgensen, 1983; Shimmield and Price, 1984; Kablanow et al., 1984; Kulm et al., 1984). Baker and Burns (1985) suggest that most of the pelagic dolomites formed within a few tens of meters below the seafloor within the zone of microbial sulfate reduction. According to Fuechtbauer and Richter (1988), dolomite can form in the deep-sea at a minimum temperature of 10°C. Other deep-sea dolomites are products of fluids derived from underlying evaporites or submarine weathering of basalts (Garrison, 1981). In some cases (Mullins et al., 1985; Dix and Mullins, 1988; Mullins et al., 1988), the existence of dolomite is linked to disconformities and its formation may have resulted from circulation of seawater through the sediment during prolonged exposure (Dix and Mullins, 1988, p. 287). At Site 768 (Fig. 1), lithified carbonate layers, some containing variable amounts of dolomite, occur below 201 mbsf (Miocene). These beds alternate with unconsolidated or semi-lithified marl layers interbedded in clays and siliciclastic turbidites. The irregular depth distribution of the limestone beds and the variation in preservation and recrystallization of the calcareous microfaunas suggest that lithification of carbonates at Site 768 not only reflects burial diagenesis as described by Garrison (1981) and others, but in part may be a selective, early diagenetic process. The different types and distribution of the dolomite additionally seem to support this assumption. The purpose of this report is to document the occurrence and textural nature of the dolomite at Site 768. Methods used were analyses of stained thin sections (Alizarin S and Ferrocyanide) and studies with the scanning electron microscope. No geochemical analyses (e.g., stable isotopes) were carried out; they will be the subject of further investigations.