The adoption of healthcare information technology (HIT) has been advocated by various groups as critical in addressing the growing crisis in the healthcare industry. Despite the plethora of evidence on the benefits of HIT, however, the healthcare industry lags behind many other economic sectors in the adoption of information technology. A significant number of healthcare providers still keep patient information on paper. With the recent trends of reimbursement reduction and rapid technological advances, therefore, it would be critical to understand differences in structural characteristics and healthcare performance between providers that do and that do not adopt HIT. This is accomplished in this research, first by identifying organizational and contextual factors associated with the adoption of HIT in US acute care hospitals and second by examining the relationships between the adoption of HIT and two important healthcare outcomes: patient safety and quality of care. After conducting literature a review, the structure-process-outcome model and diffusion of innovations theory were used to develop a conceptual framework. Hypotheses were developed and variables were selected based on the conceptual framework. Publicly available secondary data were obtained from the American Hospital Association (AHA), the Health Information and Management Systems Society (HIMSS), and the Healthcare Cost and Utilization Project (HCUP) databases. The information technologies were grouped into three clusters: clinical, administrative, and strategic decision making ITs. After the data from the three sources were cleaned and merged, regression models were built to identify organizational and contextual factors that affect HIT adoption and to determine the effects of HIT adoption on patient safety and quality of care. Most prior studies on HIT were restricted in scope as they primarily focused on a limited number of technologies, single healthcare outcomes, individual healthcare institutions, limited geographic locations, and/or small market segments. This limits the generalizability of the findings and makes it difficult to draw definitive conclusions. The new contribution of the present study lies in the fact that it uses nationally representative latest available data and it incorporates a large number of technologies and two risk adjusted healthcare outcomes. Large size and urban location were found to be the most influential hospital characteristics that positively affect information technology adoption. However, the adoption of HIT was not found to significantly affect hospitals' performance in terms of patient safety and quality of care measures. Perhaps a remarkable finding of this study is the better quality of care performance of hospitals in the Midwest, South, and West compared to hospitals in the Northeast despite the fact that the latter reported higher HIT adoption rates. In terms of theoretical implications, this study confirms that organizational and contextual factors (structure) affect adoption of information technology (process) which in turn affects healthcare outcomes (outcome), though not consistently, validating Avedis Donabedian's structure-process-outcome model. In addition, diffusion of innovations theory links factors associated with resource abundance, access to information, and prestige with adoption of information technology. The present findings also confirm that hospitals with these attributes adopted more technologies. The methodological implication of this study is that the lack of a single common variable and uniformity of data among the data sources imply the need for standardization in data collection and preparation. In terms of policy implication, the findings in this study indicate that a significant number of hospitals are still reluctant to use clinical HIT. Thus, even though the passage of the American Recovery and Reinvestment Act (ARRA) of 2009 was a good stimulus, a more aggressive policy intervention from the government is warranted in order to direct the healthcare industry towards a better adoption of clinical HIT.

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Bildgesteuerte, perkutane Interventionen stellen bei vielen diagnostischen und therapeutischen Fragestellungen eine Alternative zum chirurgischen Vorgehen dar. Hierbei kommen bevorzugt die Sonographie und die Computertomographie (CT) zum Einsatz. Zu den Indikationen für eine gezielte Nutzung der Magnetresonanztomographie (MRT) zählen Befunde, die sich mit anderen Modalitäten nicht ausreichend darstellen lassen, die fehlende Strahlenexposition (CT) sowie Alleinstellungsmerkmale wie der hervorragende native Weichteilkontrast oder die Möglichkeiten zur Darstellung von Temperaturen oder Diffusionsprozessen. Zu den Nachteilen zählen die langen Messzeiten, das starke Magnetfeld sowie die räumliche Enge in den meist röhrenförmigen Geräten, die ein interventionelles Vorgehen oft erschweren. Stereotaktische Führungs- und Navigationshilfen sind kein notwendiger Bestandteil der interventionellen Ausrüstung, ermöglichen jedoch oft eine gezieltere Planung, bessere Visualisierung oder vereinfachte Durchführung, insbesondere gegenüber einer rein kognitiven Einbeziehung der MRT-Informationen. Assistenzsysteme für geschlossene MRT-Geräte sind meist rahmenbasiert und beschränken sich auf bestimmte Regionen, z. B. die Mamma, die Prostata oder das muskuloskelettale System. Diese Arbeit beschreibt hingegen eine leistungsstarke rahmenlose Assistenztechnik (Navigation), die sich praktisch in beliebigen Körperregionen einsetzen lässt. Der Operateur orientiert sich dabei anhand von hochwertigen MRT-Ansichten, die gemäß der in Echtzeit erfassten Nadellage aus einem kurz zuvor erhobenen Referenzdatensatz reformatiert werden. Ausgehend von der Implementierung an einem speziellen offenen MRT-System (0,5 T) werden interventionelle Komponenten und Methoden beschrieben, die erfolgreich auf ein herkömmliches MRT-System (1,5 T) übertragen wurden. Die Einschränkungen des geschlossenen Systems führten dabei zu einer speziellen Registrierungstechnik mit Hilfe einer kompakten, frei positionierbaren Referenzplatte mit resonanten Miniatur-Hochfrequenzspulen (semiaktiv) als MR-Positionsmarker. Im Vordergrund stand die systematische Prüfung der Marker hinsichtlich Signalverhalten und Sicherheit sowie die Zuverlässigkeit und Genauigkeit einer vollautomatischen, bildbasierten 3D-Lokalisation unter experimentellen und klinischen Randbedingungen. Gegenüber herkömmlichen, passiven (Kontrastmittel-) Markern zeichnet sich die semiaktive Technik dadurch aus, dass sie gleichzeitig, auch mehrere, beliebig über das gesamte Messvolumen verteilte Marker, praktisch unabhängig von sämtlichen anatomischen Strukturen lokalisieren kann. Sowohl die Festlegung einer Position (ein Marker) oder einer Ebene (drei Marker) wie auch die navigierte Platzierung einer Nadel zeigten im Experiment ausreichend hohe Genauigkeiten. Auf Basis einer zeitlich optimierten (Subsekunden-) Markerbildgebung konnte experimentell eine robotisch geführte Nadel direkt im MRT bildgebend verfolgt werden, was weitere Anwendungen der Lokalisationstechnik in Aussicht stellt. Navigierte Biopsien an einem Gewebephantom zeigten nach ausschließlich stereotaktischer Positionierung – ohne Kontrollbildgebung – unabhängig vom Erfahrungsgrad der medizinischen Anwender ausreichend hohe Trefferquoten. Gleichzeitig lieferte die Studie wertvolle, auch anwenderspezifische Erkenntnisse über die Bedienbarkeit sowie den Zeitbedarf für einzelne Interventionsschritte. Im Vergleich mit anderen prototypischen oder kommerziellen Systemen zeigte sich die vorgestellte Assistenztechnik – am Beispiel muskuloskelettaler Interventionen – als klinisch flexibel einsetzbar.

Thesis advisor: John J. Michalczyk / The internet is changing health care right under out very noses. In doing so, it may have great impact on the physician-patient relationship. This relationship exists along a continuum, with paternalism at one end and total patient autonomy at the other. Various aspects of web-based health care (eHealth) are pushing the equilibrium one way or the other. Aspects of eHealth considered include: general health information websites, internet pharmacies, health communication infrastructures (as in physician-patient email and electronic medical records), and finally web-brokered organ transplantation. While there is obviously much to be aware of in terms of quality on the internet, it is concluded that an integration of eHealth into traditional medicine (thus creating cybermedicine) may not only help to mitigate the managed care crisis, but may also change the physician-patient relationship—hopefully for the better. / Thesis (BS) — Boston College, 2005. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: College Honors Program.

Immune heparin-induced thrombocytopenia (HIT) is a potentially serious complication of heparin therapy and is associated with antibodies directed against a complex of platelet factor 4 (PF4) and heparin. Early diagnosis of HIT is important to reduce morbidity and mortality. I developed an enzyme immunoassay that detects the binding of HIT IgG to PF4-heparin in the fluid phase. This required techniques to purify and biotinylate PF4. The fluid phase assay produces consistently low background and can detect low levels of anti-PF4-heparin. It is suited to testing alternative anticoagulants because, unlike in an ELISA, a clearly defined amount of antigen is available for antibody binding. I was able to detect anti-PF4-heparin IgG in 93% of HIT patients. I also investigated cross-reactivity of anti-PF4-heparin antibodies with PF4 complexed to alternative heparin-like anticoagulants. Low molecular weight heparins cross-reacted with 88% of the sera from HIT patients while half of the HIT sera weakly cross-reacted with PF4-danaparoid (Orgaran). The thrombocytopenia and thrombosis of most of these patients resolved during danaparoid therapy, indicating that detection of low affinity antibodies to PF4-danaparoid by immunoassay may not be an absolute contraindication for danaparoid administration. While HIT patients possess antibodies to PF4-heparin, I observed that HIT antibodies will also bind to PF4 alone adsorbed on polystyrene ELISA wells but not to soluble PF4 in the absence of heparin. Having developed a technique to affinity-purify anti-PF4-heparin HIT IgG, I provide the first estimates of the avidity of HIT IgG. HIT IgG displayed relatively high functional affinity for both PF4-heparin (Kd=7-30nM) and polystyrene adsorbed PF4 alone (Kd=20-70nM). Furthermore, agarose beads coated with PF4 alone were almost as effective as beads coated with PF4 plus heparin in depleting HIT plasmas of anti-PF4-heparin antibodies. I conclude that the HIT antibodies which bind to polystyrene adsorbed PF4 without heparin are largely the same IgG molecules that bind PF4-heparin and thus most HIT antibodies bind epitope(s) on PF4 and not epitope(s) formed by part of a PF4 molecule and part of a heparin molecule. Binding of PF4 to heparin (optimal) or polystyrene/agarose (sub-optimal) promotes recognition of this epitope. Under conditions that are more physiological and sensitive than previous studies, I observed that affinity-purified HIT IgG will cause platelet aggregation upon the addition of heparin. Platelets activated with HIT IgG increased their release and surface expression of PF4. I quantitated the binding of affinity-purified HIT 125I-IgG to platelets as they activate in a plasma milieu. Binding of the HIT IgG was dependent upon heparin and some degree of platelet activation. Blocking the platelet Fc??? receptor-II with the monoclonal antibody IV.3 did not prevent HIT IgG binding to activated platelets. I conclude that anti-PF4-heparin IgG is the only component specific to HIT plasma that is required to induce platelet aggregation. The Fab region of HIT IgG binds to PF4-heparin that is on the surface of activated platelets. I propose that only then does the Fc portion of the bound IgG activate other platelets via the Fc receptor. My data support a dynamic model of platelet activation where released PF4 enhances further antibody binding and more release.

本研究動機在以有系統的方式來探討產品生命週期相當短暫的流行產業，即唱片、服飾、出版、電影及電視遊樂器等五項產業；同時由於此類產業產品生命週期短暫的特性，傳統的產品／市場分析方式已不再適用，作者擬以新興的資源基礎論的觀點來分析流行產業，同時在國際化風潮盛行的今天，國際化是一不容忽視的議題，延續上述說明，本研究將以資源基礎的觀點來討論企業國際化策略之選擇。本研究目的如下： 　　1.建構適當的分類構面，對流行產業做適當分類，以獲取更多資訊 　　2.找出流行產業核心資源。 　　3.研究核心資源與國際化策略之對應關係。 　　在研究方法上，本研究係屬於探索性之研究，目前理論仍在發展階段，並無十分完整的理論架構。因此本研究擬採個案研究法進行。首先本研究根據次級資料的蒐集與實務現象的瞭解，認為「唱片業」與「服飾業」是流行產業中風格殊異的兩類產業，故選擇此兩產業為主要研究之產業代表樣本。另外，本研究的觀念架構包括核心技術類型、核心資源組合、核心資源特性，以及國際化策略四大變項，藉由選取唱片與服飾業中代表性的廠商A、B、C、D公司，深入訪談該企業之核心技術類型、核心資源與國際化策略，據以分析其間關係。 　　在研究結論方面，整理結果如下： 　　一、流行產業可區分為「流行主體專屬性高者」與「流行主體專屬性低者」，兩者之關鍵成功因素有別。 　　二、流行產業中有三種不同的核心技術類型，即「掘井型」、「汲水型」，及「配送型」。 　　三、唱片業與服飾業中，核心技術類型間交易標的物、交易商品獨特程度、交易頻次不同，故統治方式不同。 　　四、流行產業中核心資源組合決定於其核心技術類型。掘井型者核心資源組合應為契約網路、非契約網路、行銷能力、企業文化、個人專業技術能力，及個人人際網路。汲水型者核心資源組合為設備與調配能力。配送型者的核心資源組合為配銷通路的蜜集程度與陳列位置優列、促銷能力與品牌。 　　五、企業擁有不同核心資源組合，由於核心資源特性有別，應採用不同的國際化策略。 　　六、不同核心技術類型者，由於核心資源組合、核心資源特性不同，應採用不同的國際化策略。

Much experimental evidence shows that the cytoskeleton is a downstream target and effector during cell death in numerous neurodegenerative diseases, including Parkinson's, Huntington's, and Alzheimer's diseases. However, recent evidence indicates that cytoskeletal dysfunction can also trigger neuronal death, by mechanisms as yet poorly understood. We studied a mathematical model of cytoskeleton-induced neuron death in which assembly control of the neuronal cytoskeleton interacts with both cellular stress levels and cytosolic free radical concentrations to trigger neurodegeneration. This trigger mechanism is further modulated by the presence of cell interactions in the form of a diffusible toxic factor released by dying neurons. We found that, consistent with empirical observations, the model produces one-hit exponential and sigmoid patterns of cell dropout. In all cases, cell dropout is exponential-tailed and described accurately by a gamma distribution. The transition between exponential and sigmoidal is gradual, and determined by a synergetic interaction between the magnitude of fluctuations in cytoskeleton assembly control and by the degree of cell coupling. We concluded that a single mechanism involving neuron interactions and fluctuations in cytoskeleton assembly control is compatible with the experimentally observed range of neuronal attrition kinetics. We also studied the transit of neurons through states intermediate between initial viability and cell death. We found that the stochastic flow of neuron fate, from viability to cell death, self-organizes into two distinct temporal phases. There is a rapid relaxation of the initial neuron population to a more disordered phase that is long-lived, or metastable, with respect to the time scales of change in single cells. Strikingly, cellular egress from this metastable phase follows the one-hit kinetic pattern of exponential decline now established as a principal hallmark of cell death in neurodegenerative disorders. Intermediate state metastability may therefore be an important element in the systems biology of one-hit neurodegeneration. Further, we studied the full spatiotemporal dynamics of death factor pulses released from dying neurons to emphasize the effects of the cell-to-cell coupling strength on neuron death rates. The rate of neuron cell loss monotonically increased with increased diffusion-dependent intercellular communication. Death factor diffusion effects may therefore be important moderators of one-hit neurodegeneration.

Much experimental evidence shows that the cytoskeleton is a downstream target and effector during cell death in numerous neurodegenerative diseases, including Parkinson's, Huntington's, and Alzheimer's diseases. However, recent evidence indicates that cytoskeletal dysfunction can also trigger neuronal death, by mechanisms as yet poorly understood. We studied a mathematical model of cytoskeleton-induced neuron death in which assembly control of the neuronal cytoskeleton interacts with both cellular stress levels and cytosolic free radical concentrations to trigger neurodegeneration. This trigger mechanism is further modulated by the presence of cell interactions in the form of a diffusible toxic factor released by dying neurons. We found that, consistent with empirical observations, the model produces one-hit exponential and sigmoid patterns of cell dropout. In all cases, cell dropout is exponential-tailed and described accurately by a gamma distribution. The transition between exponential and sigmoidal is gradual, and determined by a synergetic interaction between the magnitude of fluctuations in cytoskeleton assembly control and by the degree of cell coupling. We concluded that a single mechanism involving neuron interactions and fluctuations in cytoskeleton assembly control is compatible with the experimentally observed range of neuronal attrition kinetics. We also studied the transit of neurons through states intermediate between initial viability and cell death. We found that the stochastic flow of neuron fate, from viability to cell death, self-organizes into two distinct temporal phases. There is a rapid relaxation of the initial neuron population to a more disordered phase that is long-lived, or metastable, with respect to the time scales of change in single cells. Strikingly, cellular egress from this metastable phase follows the one-hit kinetic pattern of exponential decline now established as a principal hallmark of cell death in neurodegenerative disorders. Intermediate state metastability may therefore be an important element in the systems biology of one-hit neurodegeneration. Further, we studied the full spatiotemporal dynamics of death factor pulses released from dying neurons to emphasize the effects of the cell-to-cell coupling strength on neuron death rates. The rate of neuron cell loss monotonically increased with increased diffusion-dependent intercellular communication. Death factor diffusion effects may therefore be important moderators of one-hit neurodegeneration.