Persistent facial pain in post-stroke patients, a hospital-based cohort study; experience from North India

Background

Post-stroke pain is common after a stroke and might be underreported. We describe Persistent Facial Pain (PFP) developed in post-stroke patients.

Method

ology: This was a prospective hospital-based cohort study of stroke patients, and patients were followed up. Out of 415 stroke patients, 26 developed PFP.

Result

Out of all PFP patients, six patients had an ischemic stroke, and 20 had a hemorrhagic stroke. 57.7% of patients had hypertension, while 34.6 patients had diabetes. The stroke location was left-sided in 12 patients and right-sided in 14 patients. 46.15% of patients responded to venlafaxine, 30.77% responded to amitriptyline, and 23.08% responded to pregabalin.

Conclusion

Persistent facial pain is a pain syndrome that might be missed in patients post-stroke. It might be more common in hemorrhagic stroke patients than in ischemic stroke patients. It responds adequately to antidepressants. A high index of suspicion is required to diagnose and appropriately manage these patients.

The effect of low dose thyroid replacement therapy in patients with episodic migraine and subclinical hypothyroidism: A randomised placebo-controlled trial

INTRODUCTION

Migraine is a common headache syndrome associated with various other comorbidities. Thyroid replacement in migraine patients with hypothyroidism improves headaches; however, thyroid hormone replacement in subclinical hypothyroidism is debatable, and its efficacy is not known.

OBJECTIVE AND METHODOLOGY

This prospective, single-centre, quasi-randomised interventional study was conducted on patients visiting the General Medicine and Neurology outpatient department at a tertiary centre to look at the efficacy of thyroxine in subclinical hypothyroidism.

RESULTS

We assessed 87 patients for analysis; no patients were lost to follow-up. There was a decrease in all parameters evaluated (headache frequency, severity, duration, MIDAS score, MIDAS grade) at three months of follow-up in the treatment group compared to placebo group. There was a significant decrease in headache frequency and severity in the levothyroxine group compared to the placebo group at three months of follow-up. Also, the follow-up MIDAS score (mean ± SD: 6.30 ± 2.455 scores vs. 8.45 ± 5.757 scores) was significantly decreased by treatment at three months follow-up.

CONCLUSION

Treatment of subclinical hypothyroidism effectively reduces migraine headaches, and it is logical to check thyroid function status in patients presenting with migraine headaches. However, a larger randomised controlled trial is required to prove the efficacy of levothyroxine in migraine with subclinical hypothyroidism.

Wide-awake local anesthesia and no tourniquet (WALANT) in upper limb fractures

Wide-awake local anesthesia and no tourniquet (WALANT), first used for hand surgery, has been sparingly described for use in fracture fixation of the upper limb. We present our experience using this technique. 26 patients with upper limb fractures (3 distal radius, 6 radial shaft, 11 ulnar shaft, and 6 olecranon fractures) were operated on using WALANT by three orthopedic surgeons. We used 35-40ml of 2% Lignocaine with 1:80000 Adrenaline(7mg/kg) diluted with normal saline. Numeric Pain Rating (NPR) scoring was done during injection and per-operatively, and the Likert scale was used for the surgeon's satisfaction. The average NPR score was reported as 0.65 (1-3) during injection and 0.15 (0-2) preoperatively. All three surgeons reported excellent satisfaction in all the cases operated on. No complication occurred due to anesthesia. WALANT is a much simpler option and can be safely used in place of general anesthesia or regional blocks for fixation of fractures of the upper limb, with added advantages of no need for a tourniquet and better intraoperative assessment of fracture fixation.

Effect Of Persistent Organic Pollutants In Patients With Ischemic Stroke And All Stroke: A Systematic Review And Meta-Analysis

The role of environmental contaminants and their association with stroke is still being determined. Association has been shown with air pollution, noise, and water pollution; however, the results are inconsistent across studies. A systematic review and meta-analysis of the effect of persistent organic pollutants (POP) in ischemic stroke patients were conducted; a comprehensive literature search was carried out until 30^th June 2021 from different databases. The quality of all the articles which met our inclusion criteria was assessed using Newcastle-Ottawa scaling; five eligible studies were included in our systematic review. The most studied POP in ischemic stroke was polychlorinated biphenyls (PCBs), and they have shown a trend for association with ischemic stroke. The study also revealed that living near a source of POPs contamination constitutes a risk of exposure and an increased risk of ischemic stroke. Although our study provides a strong positive association of POPs with ischemic stroke, more extensive studies must be conducted to prove the association.

Platelet function suggests cardioembolic aetiology in cryptogenic stroke

Platelet-monocyte (PMA) and platelet-neutrophil aggregations (PNA) play critical roles in the evolution of acute ischemic stroke (AIS). The present study investigates the mechanistic basis of platelet responsiveness in cryptogenic stroke compared with cardioembolic stroke. Platelet from 16 subjects, each from cryptogenic and cardioembolic stroke groups and 18 age-matched healthy controls were subjected to different investigations. Compared to healthy controls, platelet-monocyte and platelet-neutrophil interactions were significantly elevated in cryptogenic (2.7 and 2.1 times) and cardioembolic stroke (3.9 and 2.4 times). P-selectin expression on platelet surface was 1.89 and 2.59 times higher in cryptogenic and cardioembolic strokes, respectively, compared to healthy control. Cell population with [Ca²⁺_i] in either stroke group was significantly outnumbered (by 83% and 72%, respectively, in cryptogenic and cardioembolic stroke) in comparison to healthy controls. Noteworthy, TEG experiment revealed that the cryptogenic stroke exhibited significant decline in Reaction Time (R) and amplitude of 20 mm (K) (by 32% and 33%, respectively) while thrombin burst (α-angle) was augmented by 12%, which reflected substantial boost in thrombus formation in cryptogenic stroke. Although TEG analysis reveals a state of hypercoagulability in patients with cryptogenic stroke. However, platelets from both stroke subtypes switch to a 'hyperactive' phenotype.

Neuro-Leptospirosis: Experience from a tertiary center of North India

Leptospirosis is a common zoonotic disease, especially in agricultural countries. Neurological manifestations of leptospirosis (neuroleptospirosis) have been reported in a study with a small number of patients. Here we report seven consecutive patients with neuroleptospirosis admitted to a neurology ward. All seven patients had a meningoencephalitis-like presentation. Leptospirosis was confirmed by polymerase chain reaction. None of the patients had systemic involvement. All patients responded significantly to intravenous ceftriaxone and oral doxycycline, recovering completely. Diagnosis of neuroleptospirosis should always be considered in patients with acute meningoencephalitis along with bacterial and viral encephalitis. Prognosis is good with early diagnosis and appropriate treatment.

Blood and CSF biomarkers for post-stroke epilepsy: a systematic review

Post-stroke epilepsy is a common complication of ischemic stroke which adversely affects the prognosis of patients. Clinical and radiological parameters cannot adequately predict the risk. Therefore, the discovery of biomarkers is imperatively needed for predicting post-stroke epilepsy. We conducted a systematic review of diagnostic and prognostic biomarkers for post-stroke epilepsy through a comprehensive literature search in different databases. All articles that met our inclusion criteria were assessed for quality using the modified Quality Assessment of Diagnostic Accuracy Studies questionnaire. Eight eligible studies were included in this systematic review. Out of 22 assessed biomarkers, nine biomarkers showed significant association with post-stroke epilepsy. The T allele of CD40 (cluster of differentiation 40) −1C/T polymorphism, the CC genotype of TRPM6 (transient receptor potential cation channel subfamily M member 6) rs2274924, the allele polymorphism of MAD2 (mitochondrial aldehyde dehydrogenase 2), the mRNA level of interleukin-6 (IL-6), the plasma level of endostatin, and the mRNA expression of IL-1β show a positive correlation with post-stroke epilepsy; while S100 calcium-binding protein B, heat shock 70 kDa protein-8 and neuropeptide Y are inversely associated with post-stroke epilepsy. As a small number of patients were recruited, further studies are needed to confirm their potential use for predicting post-stroke epilepsy.

Impact of COVID-19 on Guillain-Barre Syndrome in India: A Multicenter Ambispective Cohort Study

Introduction/Aims

Studies conducted during the coronavirus disease 2019 (COVID-19) pandemic have reported varied data regarding the incidence of Guillain-Barre syndrome (GBS). The present study investigated demographic and clinical features, management, and outcomes of patients with GBS during a specified period of the COVID-19 pandemic, and compared these features to those of GBS in the previous year.

Methods

A multicenter, ambispective cohort study including 26 centers across India was conducted. Data from a pre-COVID-19 period (March 1 to August 31, 2019) were collected retrospectively and collected ambispectively for a specified COVID-19 period (March 1 to August 31, 2020). The study was registered with the Clinical Trial Registry India (CTRI/2020/11/029143).

Results

Data from 555 patients were included for analysis: pre-COVID-19 (n = 334) and COVID-19 (n = 221). Males were more commonly affected during both periods (male:female, 2:1). Gastroenteritis was the most frequent antecedent event in 2019 (17.4%), whereas fever was the most common event in 2020 (10.7%). Paraparesis (21.3% versus [vs.] 9.3%, P = 0.001) and sensory involvement (51.1% vs. 41.3%; P = 0.023) were more common during COVID-19 in 2020, whereas back pain (26.3% vs. 18.4%; P = 0.032) and bowel symptoms (20.7% vs. 13.7%; P = 0.024) were more frequent in the pre-COVID period. There was no difference in clinical outcomes between the two groups in terms of GBS disability score at discharge and 3 months after discharge. Independent predictors of disability in the pre-COVID period included areflexia/hyporeflexia, the requirementfor intubation, and time to bulbar weakness; in the COVID-19 period, independent predictors included time from onset to admission, intubation, and intubation requirement. The mortality rate was 2.3% during the entire study period (13/555 cases).

Discussion

Results of this study revealed an overall reduction in the frequency of GBS during the pandemic. The lockdown likely reduced the risk for antecedent infections due to social distancing and improved hygiene, which may have resulted in the reduction of the frequency of GBS.

Systematic Review and Meta-analysis of Environmental Toxic Metal Contaminants and the Risk of Ischemic Stroke

Background

Stroke is the second largest cause of mortality (WHO 2014) and long-lasting disability worldwide. Many risk factors are associated with stroke, such as age, gender, chronic illnesses, cardiovascular disease, lifestyle, and smoking. With global industrialization, the roles of environmental contaminants and their association with stroke are still unclear and have attracted much more attention.

Materials and Methods

We conducted a systematic review on the environmental toxic metal contaminants and the risk of ischemic stroke. A comprehensive literature search was carried out till June 30, 2021 from databases such as PubMed, Science Direct, Embase, and Scopus. The quality of all the articles which met our inclusion criteria was assessed using Newcastle-Ottawa scaling, and four eligible studies were included for our systematic review.

Results

The serum and urine cadmium concentrations were positively associated with the risk of ischemic stroke. There was an inverse association of serum and urine concentrations of mercury (Hg), serum concentration of gold and cerium with ischemic stroke, and the serum and urine concentrations of lead (Pb) had no association with ischemic stroke risk.

Conclusion

The study showed strong associations between heavy metals and ischemic stroke, but more studies are required to prove the associations.

Case-control study of vitamin D status and adult multidrug-resistant pulmonary TB

BACKGROUND: India has the highest prevalence of multidrug-resistant TB (MDR-TB) globally. Vitamin D deficiency is potentially an important risk factor for MDR-TB.METHODS: We conducted a case-control study of 90 newly diagnosed adult MDR-TB cases, 180 household controls and 82 non-household controls in Mumbai, India. Serum 25-hydroxyvitamin D (25(OH)D), anthropometry, clinical status and history, dietary data and sociodemographic data were collected from each participant. Interferon-gamma release assay (IGRA) was also performed in controls to assess latent TB. Multivariable regression was performed to estimate associations between 25(OH)D vs. case status and IGRA positivity.RESULTS: Mean participant age was 33.8 ± 12.0 years; 72.8% had 25(OH)D <20 ng/ml. Mean 25(OH)D was significantly (P < 0.05) lower in cases (12.5 ± 7.9) than both household (17.5 ± 11.2) and non-household controls (16.4 ± 9.1). In multivariable models, 25(OH)D concentration was inversely associated with MDR-TB case status among cases and household controls (OR 0.95 per 1 ng/ml, 95% CI 0.92-0.99; P = 0.015), and among cases and non-household controls (OR 0.94 per 1 ng/ml, 95% CI 0.89-1.00; P = 0.033); 53.6% of controls were IGRA-positive. 25(OH)D status was not associated with IGRA positivity.CONCLUSION: Vitamin D status was independently associated with MDR-TB case status. Research should evaluate the effectiveness of vitamin D supplementation in prevention and adjunctive treatment of MDR-TB.

Raised Blood Urea Nitrogen-Creatinine Ratio as a Predictor of Mortality at 30 Days in Spontaneous Intracerebral Hemorrhage: An Experience from a Tertiary Care Center

Background

Spontaneous intracerebral hemorrhage (SICH) accounts for 7.5%-30% of all strokes and carries higher morbidity and mortality. Raised blood urea nitrogen and creatinine ratio (BUNR) is a marker of dehydration and related to poor outcome in stroke patients. However, the ratio varies between 15 and 80 in different studies. The aim of the present study was to assess BUNR as an independent predictor of mortality and its sensitivity and specificity in predicting outcome in the SICH population.

Materials and Methods

Patients above the age of 18 years with SICH who were admitted in the Department of Neurology at Sir Sunderlal Hospital, Banaras Hindu University between January 2018 and July 2020 were enrolled in the study and prospectively followed up. Demographic, clinical, radiological, and outcome parameters were recorded.

Results

A total of 217 patients were included. Of these, 137 (63%) were males. Seventy-one patients died during the initial 30 days. Number of patients with intraventricular hemorrhage (IVH; P = 0.003), higher mean intracerebral hemorrhage (ICH) volume (P < 0.001) and midline shift (P = 0.021), and poor Glasgow Coma Scale (GCS) score (<9) (P = 0.040) was more in the group which did not survive. Mean level of urea was significantly lower among survivors than in those who died (P = 0.001). BUNR was also significantly higher in those who died than in those who survived (P = 0.001). BUNR with a cutoff value of 39.17 was significantly associated with mortality at 30 days with a sensitivity and specificity of 61.97% and 62.33%, respectively. On performing two different multivariable logistic studies, it was found that model B with BUNR ratio as a predictor of mortality out performed model A (without BUNR).

Conclusions

The study showed that SICH was associated with significant mortality. Independent predictors of death at 30 days were lower GCS on admission, larger hematoma volume, and BUNR of more than 39.17.

Use of Ceftriaxone as a Predictor of Good Outcome in Stroke Patients: A Retrospective Chart Review

Background:

Whether ceftriaxone (CEFT) has any added advantage other than its antibiotics effect in stroke as a neuroprotective agent is not known, and this forms the base of this study.

Purpose:

We tried to assess the predictive role of the use of CEFT with respect to outcome in stroke patients.

Methods:

A retrospective chart review was conducted from a stroke registry over consecutive stroke patients admitted at a tertiary teaching institute from January 2017 to December 2018. Patients were categorized into three groups on the basis of antibiotics they received; patients without antibiotic treatment (NAB), piperacillin plus tazobactam treatment, and the CEFT treatment group. The outcome was assessed by the modified Rankin Scale at three months in good (0–3) and poor outcomes (4–6).

Results:

A total of 390 stroke patients were analyzed with ages ranging between 20 and 95 years and 151 of them were females. It was found that the severity at three months was significantly lower in those patients who were given CEFT antibiotic ( P = 0.04; OR = 0.626; 95% CI [0.396, 0.990]).

Conclusion:

Stroke patients in CEFT-treated group have a better outcome compared to piperacillin–tazobactam therapy or without antibiotics use at three months. This study indicates the possibility of an additional neuroprotective effect of CEFT apart from its antibacterial property.

The Bobath Concept (NDT) as rehabilitation in stroke patients: A systematic review

Background and Objectives:

The Bobath approach, also known as neurodevelopmental treatment (NDT), is a widely used concept in the rehabilitation of stroke patients with hemiparesis in many countries. This technique is being used since years all over the world; however, strong evidence of its usefulness is still not present. This review is aimed to find out its effectiveness based on the randomized controlled trials in the rehabilitation of stroke patients with motor disability and to compare it with other therapeutic techniques.

Materials and Methods:

A systematic literature search on PubMed Central, Science-Direct, Cochrane, Scopus, Clinical Trial Database, and Indian Clinical Trial Registry in English till 31^st July 2021 was undertaken. The review is published in Prospective Register of Systematic Reviews (PROSPERO) with registration number “CRD42019125400.” Physiotherapy Evidence-based Database (PEDro) score has been used for the quality assessment of the studies. Randomized clinical trials that studied the comparative effect of the NDT/Bobath concept on motor activity outcomes and cognition/behavior in stroke patients in comparison with other rehabilitative techniques were included.

Results:

No strong documentation describing the effectiveness of this neuro-developmental treatment or its supporting neuro-developmental treatment in comparison with other advanced neuro-physiotherapeutic techniques has been found so as to consider it as the recommended treatment for post-stroke hemiplegia/hemiparesis. Methodological aspects of selected studies for further research are suggested.

Interpretation and Conclusions:

This study is inconclusive in determining the effectiveness of the Bobath approach for the movement rehabilitation of stroke patients. These results are similar to the results of previous reviews done on the same topic.

Blood Biomarkers for the Differentiation of Cardiac Ischemic Stroke Subtypes: A Systematic Review

BACKGROUND

Blood biomarkers are a cost-effective and valid method to diagnose ischemic stroke and differentiate its subtypes in countries with poor resources.

OBJECTIVE

To perform a systematic review of published literature evaluating the diagnostic utility of blood-based biomarkers to diagnose and differentiate the etiology of ischemic stroke.

METHODS

A comprehensive literature search was carried out till December 2017 in major scientific and medical databases including PubMed, Cochrane, OVID and Google Scholar. Modified Quality Assessment of Diagnostic Accuracy Studies questionnaire was used to assess the methodological quality of each study.

RESULTS

Twenty-six studies were identified relevant to our systematic review. Various biomarkers have been studied, though only a few biomarkers such as a B-type natriuretic peptide (BNP) and Ddimer have proved their clinical utility. None of the other tested biomarkers appeared to have consistent results to diagnose ischemic stroke subtypes. Most of the studies had limitations in the classification of ischemic stroke, sample size, sample collection time, methods, biomarker selection and data analysis.

CONCLUSION

Our systematic review does not recommend the use of any blood biomarker for clinical purposes based on the studies conducted to date. BNP and D-dimer may present optimal biomarker for diagnosis and differentiation of ischemic stroke. However, large well-designed clinical studies are required to validate utility of these biomarkers to differentiate subtypes of ischemic stroke.

Competencies for a Canadian orthopaedic surgery core curriculum

We have developed a list of 281 competencies deemed to be of importance in the training of orthopaedic surgeons. A stratified, randomised selection of non-university orthopaedic surgeons rated each individual item on a scale 1 to 4 of increasing importance. Summary statistics across all respondents were given. The mean scores and sds were computed. Secondary analyses were computed in general orthopaedics, paediatrics, trauma and adult reconstruction. Of the 156 orthopaedic surgeons approached 131 (84%) responded to the questionnaire. They rated 240 of the 281 items greater than 3.0 suggesting that competence in these was necessary by completion of training. Complex procedures were rated to be less important. The structure, delivery and implementation of the curriculum needs further study. Learning activities are 'driven' by the evaluation of competencies and thus competency-based learning may soon be in the forefront of training programmes.

Simulated learning environments in anatomy and surgery delivered via the next generation internet

The Next Generation Internet (NGI) will provide high bandwidth, guaranteed Quality of Service, collaboration and security, features that are not available in today's Internet. Applications that take advantage of these features will need to build them into their pedagogic requirements. We present the Anatomy Workbench and the Surgery Workbench, two applications that require most of these features of the NGI. We used pedagogic need and NGI features to define a set of applications that would be difficult to operate on the current Internet, and that would require the features of the NGI. These applications require rich graphics and visualization, and extensive haptic interaction with biomechanical models that represent bony and soft tissue. We are in the process of implementing these applications, and some examples are presented here. An additional feature that we required was that the applications be scalable such that they could run on either on a low-end desktop device with minimal manipulation tools or on a fully outfitted high-end graphic computer with a realistic set of surgical tools. The Anatomy and Surgery Workbenches will be used to test the features of the NGI, and to show the importance of these new features for innovative educational applications.

End-to-end performance measurement of Internet based medical applications

We present a method to obtain an end-to-end characterization of the performance of an application over a network. This method is not dependent on any specific application or type of network. The method requires characterization of network parameters, such as latency and packet loss, between the expected server or client endpoints, as well as characterization of the application's constraints on these parameters. A subjective metric is presented that integrates these characterizations and that operates over a wide range of applications and networks. We believe that this method may be of wide applicability as research and educational applications increasingly make use of computation and data servers that are distributed over the Internet.

Reducing risk factors for eating disorders: comparison of an Internet- and a classroom-delivered psychoeducational program

This controlled trial compared Internet- (Student Bodies [SB]) and classroom-delivered (Body Traps [BT]) psychoeducational interventions for the reduction of body dissatisfaction and disordered eating behaviors/attitudes with a control condition. Participants were 76 women at a private university who were randomly assigned to SB, BT, or a wait-list control (WLC) condition. Measures of body image and eating attitudes and behaviors were measured at baseline, posttreatment, and 4-month follow-up. At posttreatment, participants in SB had significant reductions in weight/shape concerns and disordered eating attitudes compared with those in the WLC condition. At follow-up, disordered behaviors were also reduced. No significant effects were found between the BT and WLC conditions. An Internet-delivered intervention had a significant impact on reducing risk factors for eating disorders.

Effectiveness of an Internet-based program for reducing risk factors for eating disorders

This study evaluated an Internet-delivered computer-assisted health education (CAHE) program designed to improve body satisfaction and reduce weight/shape concerns--concerns that have been shown to be risk factors for the development of eating disorders in young women. Participants were 60 women at a public university randomly assigned to either an intervention or control condition. Intervention participants completed the CAHE program Student Bodies. Measures of body image and disordered eating attitudes were assessed at baseline, postintervention, and 3-month follow-up. At follow-up, intervention participants, compared with controls, reported a significant improvement in body image and a decrease in drive for thinness. This program provides evidence for the feasibility and effectiveness of providing health education by means of the Internet.

Effectiveness of an Internet-based program for reducing risk factors for eating disorders

This study evaluated an Internet-delivered computer-assisted health education (CAHE) program designed to improve body satisfaction and reduce weight/shape concerns--concerns that have been shown to be risk factors for the development of eating disorders in young women. Participants were 60 women at a public university randomly assigned to either an intervention or control condition. Intervention participants completed the CAHE program Student Bodies. Measures of body image and disordered eating attitudes were assessed at baseline, postintervention, and 3-month follow-up. At follow-up, intervention participants, compared with controls, reported a significant improvement in body image and a decrease in drive for thinness. This program provides evidence for the feasibility and effectiveness of providing health education by means of the Internet.

An analysis of technology usage for streaming digital video in support of a preclinical curriculum

Usage of streaming digital video of lectures in preclinical courses was measured by analysis of the data in the log file maintained on the web server. We observed that students use the video when it is available. They do not use it to replace classroom attendance but rather for review before examinations or when a class has been missed. Usage of video has not increased significantly for any course within the 18 month duration of this project.

New paradigms for medical decision support and education: the Stanford Health Information Network for Education

The information needs of physicians are complex and ever increasing in a world of rapidly expanding medical knowledge and a practice environment where physicians are required to know and do more with shrinking resources. Current strategies for providing clinical decision support and continuing medical education have failed, in part, because they have not provided timely, easy access to information that is current, integrated with other information and the physician's workflow, and relevant to specific questions that occur during the patient encounter. Meeting these challenges involves understanding the nature of medical knowledge, the different information needs of physicians, the clinical decision-making process, and the constraints of the physicians work environment, as well as the traditional barriers to physician education. We explore the nature of some of these challenges and propose one solution in the form of a highly integrated web-based technology--The Stanford Health Information Network for Education.

Student bodies: psycho-education communities on the web

We have developed a Web-delivered, multimedia health educational program, Student Bodies, designed to improve body satisfaction, a probable risk factor for the development of eating disorders in young women. The program includes psycho-educational content and a newsgroup for communication, and is delivered in a structured framework of weekly readings, assignments and postings to the newsgroup. Intervention group participants improved their body image, and reduced other attitudes that predispose to eating disorders.

Evaluation of a computer-mediated eating disorder intervention program

OBJECTIVE

This study evaluated an eating disorder intervention multimedia program modeled after self-help eating disorder treatment programs. It was hypothesized that women who completed the program would increase their body satisfaction and decrease their preoccupation with weight and frequency of disordered eating behaviors.

METHOD

Participants were 57 undergraduate females randomly assigned to either the intervention or control group. Psychological functioning was assessed at baseline, at 3 months postintervention, and at 3 months follow-up.

RESULTS

Intervention group subjects significantly improved their scores on all psychological measures over time. When compared to the control group, however, only the intervention group's improvements on the Body Shape Questionnaire were statistically significant.

DISCUSSION

This study has demonstrated that minimally effective eating disorder intervention programs can be delivered. A revised program that eliminates interface problems and increases the structure of the intervention is likely to be even better received and more effective.

Formative design of a virtual learning environment

Current technology for 3D visualization, modeling and interaction allows the construction of attractive virtual environments for study of anatomy, surgery and other biomedical fields. The formative methodology for designing such environments is uncharted, but necessary before committing to large scale development. We present one such methodology undertaken during the design of a learning environment for biology for high school and middle school students. We expect to extend this design methodology to the development of environments for the teaching of medical subjects.

Information frames: a new multimedia approach to Web-based learning of biology and medicine

Presentation of content in hyperlinked multimedia formats for teaching has failed using the computer's power of navigation through rich visual and auditory information. We have developed "Information Frames", an authoring tool in hypertext markup language (html) format, that allows easy utilization by technology-challenged teachers and professors, and attracts students because of interactive, design-based learning. An Information Frame contains a definition, explanation and illustration of a single concept. Topics are provided with hyperlinks to other Information Frames having related concepts that may provide prerequisite knowledge, or may raise the concept to a more integrative level. A graphical view of the linked-Information Frames presents a Concept Map of the overall topic.

The Stanford Health Information Network for Education: integrated information for decision making and learning

Although multiple decision support systems have been built for physicians, efficient delivery of valid and complete medical knowledge remains an elusive goal. In this paper we describe a new project, the Stanford Health Information Network for Education (SHINE). SHINE unifies core medical resources in an intuitive interface to support clinical decision making. Included in the description is a novel paradigm for continuing medical education (CME).

The interactive image tool: adding structure to images

The interactive image format and tool were developed by the Stanford University Medical Media and Information Technologies (SUMMIT) group to allow medical educators to add interactive annotations and outlines to medical cross-sections, gross dissections, and clinical images. The interactive image tool (IIT) format offers a general specification for adding structural information to images. The IIT format has been used to create rich databases of image/structure information which are employed in educational software created at SUMMIT. These databases consist of information which is re-usable in other applications as well as a standalone image database. Future extensions to the IIT format will provide a means to organize information based on the structure of that information rather than on the arbitrary or haphazard links of current hypertext and hypermedia information networks.

Multimedia clinical simulation based on patient records: authoring, user interface, pedagogy

As an alternative to available computer-based clinical simulations that mimic patient encounters, we developed a clinical case simulation that more closely resembles the patient record. Our system, implemented in a Macintosh program called Short Rounds, features rapid and customized case authoring by editing a structured text file, a dynamic user interface that presents a case-specific screen layout, and a pedagogical model that is suitable for teaching third-year medical students. We believe this approach allows faculty members to create multimedia case simulations in shorter periods of time than in available clinical simulations.

Transforming information for computer-aided instruction: using a Socratic Dialogue method to teach gross anatomy

Traditional teaching of anatomy can be a difficult process of rote memorization. Computers allow information presentation to be much more dynamic, and interactive; the same information can be presented in multiple organizations. Using this idea, we have implemented a new pedagogy for computer-assisted instruction in The Anatomy Lesson, an interactive digital teacher which uses a "Socratic Dialogue" metaphor, as well as a textbook-like approach, to facilitate conceptual learning in anatomy.