Traditional herbal strategies for treating lung disease are founded on supporting and tonifying the innate protective resources. This is one area where the divide between traditional and modern approaches is particularly great. There are very few modern endorsements of early treatment strategies. Modern medical science, which at first embraced such agents in the earlier part of this century, now sees no role for their use. For example, modern editions of Martindale’s Extra Pharmacopoeia claim that: “There is little evidence to show that expectorants are effective.” Some modern drugs may have expectorant activity, such as bromhexine, but they are usually referred to as ‘mucolytic’. The impact of traditional remedies on the respiratory system is relatively poorly researched. Reliable external measures of change in mucosal functions are elusive; many respiratory diseases are either self-limiting or are among some of the most persistent conditions in the clinic. (1)

However, while the traditional herbal approach is somewhat lacking in scientific support, it is not without a rational basis. This article will examine some important herbal concepts involved in supporting the innate defenses of the lungs during infection. The key concept of expectorants will be discussed in detail, with a focus on the classification of expectorants and the scientific investigations into their effects.

Part of the problem with expectorants probably arises from confusion over their definition. Another aspect of the dismissal of expectorants stems from the difficulties involved with measuring their efficacy.

The four definitions of expectorants given below highlight the difficulties. The dictionary meaning is only concerned with the actual oral production of phlegm or sputum. Since the majority of mucus produced from the lungs is swallowed, this definition is clearly unsatisfactory. Definitions from the pharmacologists Boyd and Lewis are more useful but probably the best definition comes from Brunton, a 19th century pharmacologist.

Oxford Dictionary “Promoting the ejection of phlegm by coughing or spitting.”

Boyd (1954) “An expectorant may be pharmacologically defined as a substance which increases the output of demulcent respiratory tract fluid.”

Lewis (1960) “Expectorants increase the secretions of the respiratory tract and so reduce the viscosity of the mucus which can then act as a demulcent. By virtue of the presence of increased quantities of fluid mucus, expectorants produce a “productive cough” which is less exhausting and less painful to the patient.”

Brunton (1885) “Remedies which facilitate the removal of secretions from the air passages. The secretion may be rendered more easy of removal by an alteration in its character or by increased activity of the expulsive mechanism.”

Why Expectorants?

Many respiratory conditions are characterized by abnormal mucus (catarrh) which can narrow airways. This abnormal mucus may be thick and tenacious and hence very difficult to clear from the airways. If expectorants can render this catarrh more fluid and/or assist in its expulsion, then a clinical benefit should be achieved.

Expectorants can help to relieve debilitating cough. The presence of an irritation in the airways (such as tenacious abnormal mucus) invokes the cough reflex. (The cough reflex is most sensitive in the trachea and larger airways. The sensitivity progressively decreases in the finer airways and in the very fine airways there is no reflex at all. So in alveolitis, there is little stimulation of the cough reflex, whereas for tracheitis the stimulus is strong). By clearing abnormal mucus or by changing its character and making it more demulcent, expectorants can allay cough and are therefore antitussive.

Classification of Expectorants (after Gunn, 1927)

The classification of expectorants by their mode of action is extremely valuable in understanding their appropriate use. In 1927 Gunn proposed four classes of expectorants. (2) A fifth class was suggested by the Russian scientist Gordonoff. (3)

1. Reflex expectorants

These are emetics which cause an increased secretion of respiratory tract fluid when given orally in subemetic doses. Act by reflex from the upper GIT mediated by the vagus nerve eg saponin herbs, Lobelia, Ipecac

2. Central expectorants

Act on the CNS. Possibly Ipecac

3. Parasympaticomimetics

Stimulate the vagus nerve eg Pilocarpus. Also capsaicin (in Capsicum) stimulates bronchial C-fibres

4. Stimulants of secretory cells

Act directly on goblet cells, eg essential oils

5. Secretomotorics (after Gordonoff 1938)

Stimulate mucociliary transport, eg camphor, thyme

From the herbal perspective the two most important classes are the reflex expectorants and the stimulants of secretory cells. The use of the terms stimulating or relaxing expectorants is no longer valuable, as the following quotation illustrates.

The Nevada Nurses Association invites you to celebrate nursing in this regular feature, which looks at the actions and words of nurses who made a difference. This issue addresses the need to protect the word “nurse,” the image of nursing, and the early days of state registration for nursing.

In these days of casual dress and sometimes insufficient identification, the patient has to wonder which of the persons in the health care setting is the professional nurse. Worse yet, the consumer may be even more vulnerable at the doctor’s office, when an efficient young person wearing a scrub suit, with a stethoscope around her neck calls you into the room and says,: “I’m Patsy, the nurse.” An astute consumer, noting this person’s response (or lack of) to some real medical concerns might ask Patsy about her nursing background, and learn that she is “really a medical assistant.”

The need to protect the term “nurse” seems like a new problem. Yet, it is long standing, and we must be continually willing to address it. Here is an example from American Nursing A History: (book review, this issue)

So many Society girls had romantic notions about nursing, after the United States entered what became World War I in 1917, that Clara Noyes, Director of the Red Cross Bureau of Nursing, was flooded with applications. She wrote to her friend Adelaid Nutting in desperation:

Surely we need your prayers. There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing or get their hands upon it.

Tell Annie [Goodrich] of Albany that if I were not convinced before, I should be now that the most vital thing in the life of our profession is the protection of the word nurse.

Everyone seems to have gone mad. I talk until I am hoarse,, dictating letters to doctors and [to] women who want to be Red Cross nurses in a few minutes, not knowing the meaning of the word nurse and what a Red Cross nurse is. (p.199).

After the war, Clara Noyes assigned qualified Red Cross nurses to help develop nursing programs in recovering European countries and acquired Red Cross funds to build a nursing school in Bordeaux, “France. During America’s economic depression in America she designed programs for qualified Red Cross nurses to meet people’s health needs.

Noyes was firm about the need for nurses to stay current, to take ongoing coursework, and to be involved in their professional organization. She promoted postgraduate study and often contrasted the active interest of older physicians in continuing education with the indifference of older nurse graduates.

If we are a profession, then surely there is an absolute necessity for advanced study. If we wish to see this profession placed on a strong basis, then we must be strong as a body in the fundamental principles underlying our work. If we attempt to take a position in the front ranks of the progressive movements of the age and, what is more important, stay there, we must as individuals be thoroughly prepared, and this can only be done by courses of study which have been organized on a permanent educational basis. (1905)

It comes as no surprise to any perioperative nurse that the lay public has an incomplete and sometimes erroneous perception of what perioperative nurses know and do. When a question about the adequacy of a perioperative nurse’s actions or competency is brought to the legal system, however, lay judges, juries, attorneys, or administrative law judges must make decisions as if they understood perioperative practice. To make these decisions, they cannot rely on their own knowledge; they must be assisted by documentary and testimonial evidence. More often than not, they require the assistance of an expert nurse witness. This column briefly defines the role of an expert witness, traces the evolution of the need for expert nurse witness testimony, and describes the consultative services a nurse expert can provide.

DEFINITIONS

According to Black’s Law Dictionary, an expert is

a person who, through education or
experience, has developed skill or
knowledge in a particular subject so
that he or she may form an opinion
that will assist the fact finder. (1(p619))

An expert witness is a person

qualified by knowledge, experience,
training, or education to provide a
scientific, technical, or other specialized
opinion about the evidence or a
fact issue. (1(pl633))

An expert witness differs from a material or lay witness in two respects: the expert usually has no first-hand knowledge of what led to the case and unlike material witnesses who are limited in their testimony to providing objective descriptions of what they observed or did, an expert witness is allowed to give his or her professional opinion and draw conclusions.

THE NEED FOR NURSE EXPERTS

Expert nurse witnesses typically are needed whenever the adequacy of another nurse’s actions are in question. Usually, this occurs in disciplinary proceedings against a nurse licensee before an administrative law judge or in malpractice cases where the actions of the nurse are alleged to have contributed to a patient’s injury.

For decades, most courts accepted that physicians had the necessary expertise to explain standards of nursing. More recently, it has been recognized that testimony about what a nurse should have done best comes from another nurse. For example, in 1958, a California court allowed a physician to testify about what nurses should have done saying, “Surely a qualified doctor would know what was standard procedure of nurses to follow” (Goff v Doctor’s Hospital, 166 CalApp2d 314, 319 [1958]). Fourteen years later, a Pennsylvania court recognized that a physician might not be the best expert on nursing standards, but it still allowed physicians’ testimony to be admitted because, “all areas of medical expertise within the knowledge of nurses are also within the knowledge of medical doctors” (Taylor v Spencer Hospital, 292 A2d 449, 452 [Pa Super 1972]). Finally, in 2004, an Illinois court explicitly held that a physician was not qualified to testify as to the standard of care for the nursing profession under the laws of the state of Illinois (Sullivan v Edward Hospital, 806 NE2d 645 [Ill 2004]). Along with this increasing judicial recognition of the unique body of nursing knowledge comes an increased responsibility for nurses to be willing to share their expertise with lay legal decision makers; however, they must do so within the context of the unfamiliar, adversarial legal system.

FINDING A NURSE EXPERT

Identifying a possible perioperative nurse expert is more art than science. Attorneys may conduct online searches for persons who have spoken or written on issues relevant to the case, or they may conduct a search of nursing and health care literature online or in hard copy indices. They may ask attorney colleagues for referrals or contacts. Sometimes, they contact nursing schools or professional nursing associations.

Nurses interested in offering services as consultants or witnesses can place their contact information in classified advertisements in legal journals. Some attorneys may not consult classified advertisements, however, because of concern about the credibility of the nurse expert; some states require that experts earn most of their income from the practice of the profession, not from testifying or consulting in legal cases. (2-4)

NEGOTIATING A CONTRACT

A nurse who is asked to consult or testify must approach the agreement with the retaining attorney as he or she would any other contract. The nurse expert has absolutely no duty to consult and cannot be subpoenaed to testify unless he or she consents to do so. This is a main point that should be negotiated up front. After the nurse agrees to provide a service, the nurse is legally bound by contract to do so; thus, there must be a clear expectation of services, timelines, and remuneration for time and expenses.

* Does the service consist of reviewing medical records and providing an opinion to the retaining attorney?

* Is this opinion to be an oral or written report?

Being white, female, an academic high achiever, and singleminded can have its drawbacks, but when it comes to selection for United Kingdom medical schools, no one’s better placed. At least that’s the message from the analysis by McManus of the anonymised data on selection released this week (p 1111).[1] The key findings show, surprisingly, that women are more likely to gain entry to medical schools, but candidates from ethnic minorities remain disadvantaged. Concerns about the selection procedure have long inspired calls for a code of practice.[2]

Differences exist between ethnic minority groups. Caribbeans are less disadvantaged than Africans. Indians are less disadvantaged than Bangladeshis or Pakistanis. While wide confidence intervals hint that some of these differences may not be real, it is undeniable–and suspicions are confirmed–that overall ethnic minorities are disadvantaged. Sceptics will argue that this analysis by McManus doesn’t take into account data on predicted A level grades (which were not made available to him but which selectors rely on heavily), but previous work suggests that even when academic achievement is taken into account ethnic minority candidates are less likely to be accepted, probably on the basis of their surname.[3] This adds to mounting evidence of disadvantage at all stages in the careers of ethnic minority doctors.[4-6]

McManus also finds more Subtle disadvantages. Applicants not wholly committed to medicine on their application forms, those choosing a gap year, and those from colleges of further and higher education and sixth form colleges may be less likely to gain admission to some medical schools. Older applicants and those from lower socioeconomic groups are also disadvantaged. One myth that is not substantiated, however, is that applicants from independent (private) schools are advantaged in terms of selection.

McManus points out that the new evidence raises the possibility of legal action against medical schools under section 17 of the 1976 Race Relations Act. But whether it proves racial discrimination is open to debate. Disadvantage does not necessarily equal discrimination. Legally, direct and indirect discrimination are separate concepts, with direct discrimination hinging solely on an individual’s race, while indirect discrimination arises from some hurdle in the selection procedure that is more difficult for ethnic minority candidates to clear. These data appear to raise issues of indirect discrimination, which may be difficult to prove in court (p 1117).

In the United Kingdom ethnic minorities as a whole are overrepresented in the medical profession. This is explained by the high proportion of applicants of Asian origin to medical schools as well as being a legacy of the days when overseas doctors were more welcome in the National Health Service. Even though they are disadvantaged in terms of selection, enough Asian students apply to ensure that they make up a larger proportion of the medical work force than they do of the population of the United Kingdom. Around 6% of the United Kingdom population are Asian, but they constitute 28% of medical school applicants and 21.7% of those receiving offers of a medical school place. AfroCaribbeans, meanwhile, constitute 2% of the UK population and 3.79% of medical school applicants but receive only 1.72% of offers. By contrast, 64.9% of applicants are white but they receive 74% of offers (IC McManus, personal communication).

Disadvantage, however, can be turned to advantage, as in the case of women applicants–although positive effects on career progression are yet to be seen. By contrast, medical schools in general appear unable to redress the inequalities faced by ethnic minority candidates, despite repeated focus on this issue in recent years.[7 8]

McManus confirms that some medical schools manage not to disadvantage women and ethnic minorities[3] Perhaps the answer is to learn from their admissions procedures. Alternatively, more aggressive policies may be needed; there is, for example, evidence that raising awareness of ethnic minority issues can increase recruitment.[9] Moreover, experience from the University of Arkansas has shown that lowering entry requirements for African-American applicants need not reduce standards: those same students have gone on to score above average marks in medical exams.[10]

The Council of Heads of Medical Schools is to be commended for making these data available; other selection bodies such as the police and the legal profession are much less open about their procedures, and what the deans have done should serve as a model to other professions. The council has also worked with the Commission for Racial Equality to produce an eight point list of “guiding principles” for selecting of students which will be adopted by all UK medical schools. The schools promise to review the criteria for medical student selection, both academic and non-academic; ensure that all medical schools publish and monitor equal opportunities action plans; and monitor and publish the annual figures on applications. Other proposals include further research looking into why certain applicants are disadvantaged, bringing forward the deadline for medical school applications, and reducing the number of choices available on the university application form. The Commission for Racial Equality has threatened to conduct formal investigations into medical schools that fall short.

For those of us who don’t recognize many health care abbreviations beyond DC, NCTMB means Nationally Certified in Therapeutic Massage and Bodywork. But to call The Trigger Point Therapy Workbook a discussion of massage would be akin to referring to a Monet as graffiti.

Trigger-point therapy is not new, but Janet Travell, MD, who happened to be JFK and LBJ’s White House physician, popularized it among the medical people. She was over 90 when she released the second volume of her magnum opus and close to 100 when she died. David Simons, MD, was her coauthor, aerospace physician and the former holder of the altitude record in a balloon, as well as a researcher of some note.

Together, Travell and Simons wrote the equivalent of Gray’s Anatomy of trigger points. Unfortunately, it takes a huge investment to get much from the original work. It cost over $100 and is a most technical and difficult read. It took this reviewer over six months to read both volumes from cover to cover and I still refer to it constantly. Only my medical dictionary gets more use.

So, what is the average chiropractor to do if they want to know trigger points (TPs) but don’t have the time or inclination to study Travell and Simons directly? Reading and studying The Trigger Point Therapy Workbook, by Clair Davies, which costs $19.95 and can be read in less than a week and then kept as a quick study reference, is good way to go. There are other options out there, but Davies’ work provides a quicker and cheaper introduction. There is one caveat though: The material is meant to be self-administered, but in the penultimate chapter, treatment to others is addressed.

In the chiropractic community, many of us had the pleasure of studying with Dr. Raymond Nimmo. He was this little guy from Texas with a friendly drawl, a 10-gallon hat and a knack for finding and breaking up trigger points that would just make you want to cry. Dr. Nimmo has passed on and much of his work is no longer in vogue. Dr. Cyriax, the British physician, did some brilliant work that was picked up and expanded by Dr. Warren Hammer in his treatise on soft-tissue work. Recently, Dr. Michael Leahy developed a form of dynamic palpation of muscle that is effective in stretching chronically contracted muscles, freeing traction neurodesis (a nerve that has been entrapped in muscle or other soft tissue), or just plain releasing stuck trigger points. All these other approaches require a much larger investment in time and money to get started. The Trigger Point Therapy Workbook is a tremendous bargain.

This book is a great introduction and gives the practitioner a solid place to begin examining TPs. There are interesting correlations symptomatically: dyspareunia or pain after intercourse with the abductor magnus; pseudo-anginal pain with the scalene muscles; a persistent, dry cough or pain in the top, front or sides of the head with the sternal division of the SCM (sternocleidomastoid); and dizziness, prone to lurching or falling unexpectedly, and even reversible hearing loss, with the clavicular division of the SCM.

Davies also uses the original Travell and Simons algorithm of working backward from painful areas to the list of offending muscles. Then each muscle has the likely TPs mapped out which are confirmed by palpation. Finally, if the TPs are obliterated by needling or rubbing out, there should be symptomatic improvement.

In this second edition, there are two new chapters. The first is by Amber Davies, Glair’s daughter, and in it there are illustrations and text describing massage techniques for alleviating trigger points in others. The second new chapter gets into some of the socio-psycho-physiological aspects of muscle tension. It includes some family dynamics, systemic desensitization, a subtle form of contract relax, passive flooding (giving yourself permission to be tense so you have awareness without resistance) and finally, paradoxical intention, a technique in which one confronts their fears.*

In the 323-plus pages (plus a great index), you can start using one of the most powerful, well-documented approaches in all of physical medicine. This book rates a 10 as an introduction to trigger-point work. The only practitioners this book is not recommended for are those who already have and use Travell and Simons’ trigger-point manual. Good luck and happy hunting for those pesky trigger points!

The Routledge Encyclopedia of Narrative Theory, published under the editorship David Herman, Manfred Jahn, and Marie-Laure Ryan, is more than a new dictionary of narratology. (1) It is an unprecedented work that defines and examines thousands of terms and concepts, distributed in four hundred fifty articles and related to narrative in all its forms and in all the variety of its media, formats, periods, genres, and subgenres. This innovative encyclopedia concerns students, teachers, and researchers, all those who recognize “the very predominance of narrative as a focus of interest across multiple disciplines” (x), whether in history, philosophy, psychology, anthropology, discourse analysis, or literary studies. However, we might consider whether the notion of “theory” here is likely to be a simple metaphor. The list of articles in this very rich volume can be easily divided in historical accounts (on schools or trends, such as the “Tel Aviv School of Narrative Poetics”), methodological accounts (on the different approaches to narrative, from “Computational Approaches to Narrative” to approaches more inspired by the humanities), or lexical accounts (on concepts or notions, more or less linked to the original terminology of such and such author), all accounts of varying length. The volume also contains the presentation of problems, old and new, from plot structure to the literary representation of thought and consciousness, that feed theoretical reflection on narrative. (2) The editors chose not to devote articles to individual theoreticians (but the bio-bibliographic information concerning them can be accessed through the index).

The ambition of the Encyclopedia is not only to present the history, the conceptual and methodological tools, and the terminology of narrative theory or “narrative studies” but first and foremost to underline its importance and topical interest. Apprehending two new phenomena was the main focus for the editors in their work. The first one is well known in the Anglo-Saxon world as the “narrative turn.” In the last twenty years this transformation has put the problematics of narrative at the center of not only historical, ethnographical, and psychoanalytical thought, but also juridical, political, and even medical, thus endowing narrative theory the status of a new paradigm for knowledge theory. In the article “Narrative Turn in the Humanities,” Martin Kreiswirth gives an extensive, rigorous, and well-informed presentation of this phenomenon. His article also contains a number of cross-references to the index or to other entries in the volume (see in particular “Ethnographic Approaches to Narrative,” “Historiography,” “Law and Narrative,” “Medicine and Narrative,” “Psychoanalysis and Narrative”). The “narrative turn” and the new uses it defines for the word “story” also form the subject of the first part of Ryan’s article “Narrative,” which I will come back to. The second phenomenon is the renaissance of narratology in a plural, diversified form: Narratologies, significantly, is the title of a collective work published in 1999 under the direction of David Herman. In the introduction to this work, David Herman proposes the term “postclassical narratology,” taken up in Luc Herman and Bart Vervaeck’s article, “in order to group the various efforts to transcend ‘classical’ structuralist narratology, which has been reproached for its scientificity, anthropomorphism, disregard for context, and gender-blindness” (450; also see the entries “Implied Reader,” “Narrative,” “Natural Narratolology,” “Cultural Studies Approaches to Narrative,” “Gender Studies,” and “Feminist Narratology”). However, one can wonder, when reading some of the articles in the Encyclopedia (”Education and Narrative,” “Medicine and Narrative,” “Narrative Psychology,” “Narrative Therapy,” “Theology and Narrative,” all of great interest on their own), if the encounter of certain disciplines of the “narrative turn” with the new narratology, with its postclassical and poststructuralist features, is just due to circumstances and if it does not derive from an editorial strategy rather than a true synergy.

Seeds of Central America and Southern Mexico: The Economic Species. By David L. Lentz and Ruth Dickau. xi + 296 pp. Memoirs of the New York Botanical Garden, Volume 91. The New York Botanical Garden Press, Bronx, NY, USA. 2005. US $65. ISBN 0-89327-467-4 Cloth.

This addition to the limited number of seed identification manuals is welcome, but comes with several caveats (see below). seeds of Central America and Southern Mexico: The Economic Species includes photographs and species information for over 500 economic and weedy species. Economic plants are those used for food, medicine, timber, or ornamental purposes. Each description provides: scientific name, family, both English and local common names, geographical range, habitats, growth habits, and economic uses summarized from a variety of published sources, as well as a description of the seed. The last gives shape, dimensions, color, surface characteristics, and whether appendages (e.g., wings, hairs) are present. There is a glossary, which appeared to be thorough, containing all the terms I looked up.

In order to include as many genera as possible, not all species are illustrated. Also, according to the Introduction, species illustrated in four North American works are not included (but see below). Almost all species are of New World origin. Occasionally, some species that have limited economic use or weedy status are included (e.g., Gunnera insignis Oerst.; large leaves are used as protection from rain), but their presence provides a look at seeds not found in other seed identification manuals.

All photographs have a scale bar and are black and white. Those for seeds smaller than 2 mm are scanning electronic microscope images. For seeds larger than 2 mm, a stereomicroscope was used and those larger than 10 mm were photographed using a macro lens. There is certain pleasure in looking at photographs, for example, of Begonia sericoneura seem., Manilkara zapota (L,) P. Royen, and Saurauia kegeliana Schltdl., with their elegant seed coats. Most photographs show more than one seed, providing a range of sizes, variety of shapes, or both lateral and hilum views. In some, the fruit is also shown and then fruit type (e.g., capsule, drupe stone, samara) is usually noted. Although images are generally of good quality and some excellent, others are not sharp or blend too much with the background. Soft edges, in some cases, are due to the difficulties inherent in accommodating for the seed thickness of many species.

This volume, as noted by the authors, makes available, in a readily accessible form, the Percy Wilson seed Collection, seed and fruit material from the William and Lynda Steere Herbarium, and the personal collection of Dr. Lenz built over more than 20 years of fieldwork. The first two collections are at the New York Botanical Garden, the third is at the Chicago Botanic Garden.

The accounts also provide insights into the varied uses made by local people of the plants available to them. Among them are species that also occur in North America, with ranges extending south along the mountains: Liquidambar styraciflua L. is planted as an ornamental shade tree; resin is used as incense and for flavoring, as well as to treat sores and gonorrhea; hardened gum is chewed to clean teeth; and wood is used in construction. The sap of Lobelia cardinalis L. is used to cure infection caused by imbedded thorns or wounds and fruits are edible(l). The fruit of Lycopersicon esculentum Mill, (tomato) is used for food and fresh fruit is rubbed on the neck to treat mumps. Phragmites australis (Cav.) Trin. ex Steud., a reviled invasive in North America, is used in basketry, construction (e.g., roof poles and wattle (poles interwoven with branches or reeds)), and for food, forage, and as a source of gum and medicine. The crushed rhizomes of Typha latifolia L. are used as a ‘restorative’ shampoo. (Could this be tried for greying hair?)

Species new to me: Utricularia hispida Lam., a terrestrial species, is sometimes planted as an ornamental. The latex of Castilla elastica Sessé, now used for waterproofing clothing, was used by Precolumbians to make rubber balls. Dried seeds of Pouteria sapota (Jacq.) H.E. Moore and Stearn, which is also the source of latex, medicine, and poison, are used to flavor chocolate. Finally, although many more could be cited, Rauwolfia tetraphylla L. is used to treat malaria and snake bites. (Reserpine, derived from other Rauwolfia species in other parts of the world, is used for the treatment of high blood pressure and mental illness (Mabberley 1997; The Plant Book: A Portable Dictionary of the Vascular Plants. Cambridge University Press, Cambridge, UK). It is significant that people have found medical uses for such widely separated species).

This volume brought to mind tropic forests, mountainsides, and gardens cut in the jungle or behind someone’s house that I have seen; memories of my first wild Begonia growing on a thatched roof, huge Gunnera leaves in a cold mountain reserve, and the same weedy Galinsoga that I have seen in my New Jersey garden. However despite the addition of many new images and information provided in the accounts, there are a number of additions that I believe would have made this volume more useful to those for whom it was designed, namely field biologists, wildlife managers, ecologists, agronomists, paleoethnobotanists, archaeologists, and amateurs interested in seeds. Hopefully, these can be addressed in a second addition. First, while I can appreciate the difficulties of putting together a comprehensive seed catalog for tropical southern Mexico and Central America, providing the number of species in each genus would be helpful in ascertaining whether an unknown seed can only be assigned a genus name (a caution made in the Introduction).

Illness representations have been shown to differ across cultures. The aim of the study was to study disease terminology and lay prototypes among a Northern Sotho community in South Africa. The sample for a free listing of disease terms included 41 (55%) women and 34 (45%) men, with a mean age of 36 years (SD=5.6, range 18 to 75 years). The sample for pile sorting of disease terms included 80 Northern Sotho-speaking third-year students from the University of Limpopo; 44 women, 36 men, mean age, 23.4 years (SD=3.4). From free listing of disease terms 50 were selected for pile sorting. Using hierarchical cluster analysis the following clusters could be identified: (1) respiratory problems, (2) internal body problems and sexually transmitted diseases, (3) chronic diseases and head diseases, (4) child diseases and mental problems, (5) child diseases and cancer, (6) feet problems, (7) gastrointestinal diseases. There was homogeneity of features within cluster and difference between clusters.

Understanding the layperson’s terminology of diseases is an important part of communication studies and health psychology (Lalljee, Lamb & Carnibella, 1993). Language plays a vital role in health terminology because it gives a broader definition of diseases, their causality and the possible ways of curing them. Health beliefs have been shown to be related to a wide range of processes. They include the identification of bodily signs as symptoms of particular illness, seeking professional help, compliance with medical advice, and interactions with people who suffer from that illness (see for example Bishop & Converse, 1986). Research on disease prototypes has revealed that lay illness diagnosis is influenced by symptom typicality, suggesting that it represents a “prototypematching process” (Von Lengerke, 2005). In addition to general concepts of illness, people also hold organized conceptions - termed disease prototypes - for particular diseases (Bishop 1991). For example, a person may have a disease prototype of heart disease. Similar to general illness conceptions, prototypes of specific diseases help people organize and evaluate information about bodily sensations that might otherwise not be interpretable. Thus, a person who holds the belief that he or she is vulnerable to heart disease is more likely to interpret chest pain in accord with his or her prototype of heart disease than is a person who does not hold this belief (Bishop & Converse).

Leventhal, Nerenz, and Steele (1984) suggested that illness representations have several components including the label placed upon the illness, its typical cause, and its expected consequences. Labeling a set of bodily signs as symptoms of a particular illness implies a particular set of causes, the likely duration, consequences and the method of cure (Lalljee et al., 1993). The features of representation of any particular illness are likely to be correlated rather than independent. For instance, Lau and Hartman (1983) have shown that there is a close relationship between a person’s view of the cause of an illness and his/her conception about how to cure it. Generally, the representations of different illnesses differ and little attempt has been made to investigate the relationship between beliefs about different illnesses. The analysis of disease terminology will add greater coherence and systematization to the field of linguistics and psychology. Baumann (2003) showed that illness representations differ across cultures (e.g., egocentric versus sociocentric cultures). Therefore the aim of the study was to examine disease terminology and lay prototypes in an African (sociocentric) culture with possibly linguistic specificities of a Northern Sotho community in South Africa.

METHOD

STUDY ONE: FREE LISTING OF DISEASE TERMS

Sample and procedure The sample consisted of 41 (55%) women and 34 (45%) men, with a mean age of 36 years (SD=5.6) and a range from 18 to 75 years. Purposeful sampling was used aiming at a heterogeneous sample in terms of Northern Sotho dialect, age, places of origin (rural versus urban), gender and educational level. Participants came from Mankweng, Botlokwa and Tzaneen (Medingen and Mamphakathi) villages of the Limpopo Province, South Africa. Among the Northern Sotho sample, 25 used Tlokwa dialect, 25 Lobedu dialect and 25 used Sepedi sa ga Mamabolo. With regard to the participants’ places of origin, 50 (67%) originated from a village and 25 (33%) were from an urban area. With regard to their level of education, 9 (12 %) participants had no education, 9 (12%) had primary education, 31 (41%) had secondary education and 26 (35%) had tertiary education. With regard to their marital status, 34 (45%) participants were single, 35 (47%) married, 1 (1.3%) participant was divorced and 5 (7%) widowed. With regard to their occupational status, 13 (17%) were unemployed, 5 (7%) were businessmen/women, 9 (12%) were pensioners, 10 (13%) were housewives, 22 (29%) were students and 10 (13%) had other occupations. Permission to interview the participants was obtained from the chiefs at the villages and an informed consent to participate in the study was obtained from all participants.

RANDY COLLICA IS a modern-day treasure hunter. As a senior business analyst in Palo Alto-based Hewlett-Packard Co.’s customer data and knowledge services department, his job is to mine data in search of insight that can help marketers better understand various customer segments. He stumbled upon a veritable gold mine a few years ago as he riffled through notes taken by HP’s call-center representatives. “I just knew there had to be nuggets of valuable information in there, given the volume of data we had,” says Collica. “But I also knew that finding them would be impossible if we didn’t have a tool to automate the analysis.”

Although standard data-mining systems can detect patterns hidden within structured tables of information, such as the transactional data of an ERP system, they are essentially useless with unstructured data–and notes taken during a phone call are about as unstructured as data gets. So Collica turned to text mining, a type of data-mining technology that combs through text and gives it structure so it can be analyzed.

Collica’s hunch turned out to be right: text mining revealed, as one example, that customers in lower-value segments ask a lot more questions about business processes, such as HP’s contract-negotiation procedures, than do the company’s best customers. “That insight has been invaluable in helping marketers come up with solutions and campaigns targeted at different customer groups,” says Collica.

The latest generation of technology, developed by vendors flush with post-9/11 government investment (see sidebar, page 81), is still far from perfect. But it is allowing corporations with large data sets to perform important feats they couldn’t before. “It really is the next frontier of understanding in business intelligence,” says Martin Schneider, an analyst at The 451 Group in New York.

Key to the improvements have been advances in natural language processing, a method of extracting meaning from printed words that now allows the software to “understand” complex phrases about 80 percent of the time. Text-mining systems can also be programmed to assign value to expressions. Suppose a telesales representative has entered the following note: “Nov. 15 - Cstmr not happy w/cell phone. Wants to switch to Yellow Inc.” The software can recognize that November 15 is a date; that “cstmr” is a customer; that he has a cell phone and is unhappy, which is bad; and that he wants to switch to a competitor, which is worse.

Once that kind of information is extracted, it can be structured in a format similar to a database and further analyzed, often more quickly than a human analyst can locate his reading glasses.

And the possibilities aren’t limited to customer service. San Francisco-based LoanPerformance, a provider of credit-risk-decision support tools for residential mortgage operators, uses text mining to offer its clients improved predictive analytics. Traditional risk-scoring solutions for loss mitigation and delinquency management incorporate only structured data such as a borrower’s interest rate, outstanding balance, and monthly payments. That ignores rich information that could help a mortgage servicer better determine how likely a delinquent borrower is to miss more payments or, ultimately, default. “If someone says they missed a payment because they lost their job, that’s different from ‘I forgot to send my check,” explains Damien Weldon, director of mixed-data analytics at LoanPerformance. When the company included data mined from call-center conversations in its scoring calculations, accuracy rose by 15 to 20 percent.

Text mining is finding fertile ground in the life-sciences and pharmaceutical industries, too. The brain-tumor research department at Children’s Memorial Hospital in Chicago uses text mining to comb through reams of medical journals and unearth gene-pairing information that can accelerate critical scientific breakthroughs.

Pharmaceutical companies like Pfizer Inc. mine patent documentation for insight on new directions in research. “This serves as an early-warning system to identify trends,” explains Mark Burfoot, head of information management at Pfizer in St. Louis. “We can see what competitors are doing and, by linking that information with our own R&D data, make a decision about whether it’s an area we should be looking into.”

Text mining often starts as a way to automate manual processes and then spreads as companies see its potential. At Bank of America N.A., the E-commerce team used to manually read, sort, and categorize the comments it received on surveys and feedback forums. Now text mining does the job instantly, producing graphs and charts about prevailing attitudes that help the team prioritize proposed service enhancements. Johnson Controls Inc., the Milwaukee-based autoparts supplier, first started using text mining in its call center several years ago, then began mining notes from the company’s 7,000 field-maintenance and installation engineers, searching for ways to improve products and reduce maintenance costs. More recently it has set up a program to scour Web logs and chat rooms to assess consumer opinions on car batteries. Next, the company plans to mine warranty claims for early warnings on product defects.

Clinical trial reports typically provide univariate data on adverse events in the form of rates. Little or no consideration is given to providing data on syndromes or constellations of adverse events in clinical trials. We describe three methods for analyzing adverse events; these methods focus on constellations of events within the same patient. A computer algorithm enumerates the constellations of adverse events in the data and counts the number of patients in each constellation. The proposed algorithm also preserves the identifiers of patients in the constellation and other covariates for further analysis. A log-linear model is used to estimate the magnitude of association of two or more adverse events by analyzing the count of patients in each of the possible subsets of the constellation. These methods make a unique contribution to the determination of safety in the development of new therapeutic agents.

Clinical trials provide evidence of the safety of new therapeutic agents by collecting data from a fundamental safety triad: (1) safety end points, (2) clinical laboratory values, and (3) reports of adverse events. The clinical protocol mandates the ascertainment of safety end points for every patient randomly assigned to the study. Furthermore, the protocol provides a prospective definition of safety end points and dictates the method by which these end points are determined. The clinical interpretation of clinical laboratory values is well defined (1).

During the analysis of the study, clinical laboratory values are summarized at each patient visit and are analyzed for differences between study treatments. The laboratory values are analyzed in two ways: (1) by defining extreme laboratory values as clinically significant and calculating rates of occurrence for each clinically significant value by treatment group, and (2) analysis of covariance (ANCOVA) using treatment as a factor and the baseline value as a covariate.

Both of these measurements, safety end points and clinical laboratory values, provide focused, objective measures of the safety of study medication. Adverse events, however, are broadly defined to include a wide range of medical events. The following definition of adverse events is from the International Conference on Harmonisation (ICH) Guideline for Good Clinical Practice (2):

Any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product.

Adverse events are either self-reported by the patient or provided by the investigator. The reporting of adverse events may vary from investigator to investigator because of differences among investigative sites in patterns of care and patient mix. Adverse events are reported verbatim with information on the start and stop dates of the adverse event, outcome, countermeasures, severity, and the investigator’s opinion of the relationship of the adverse event to the study medication.

The verbatim description is classified as a preferred term using an accepted dictionary of preferred terms for adverse events. Two such dictionaries are COSTART and MedDRA (3). During analysis of the study, the resulting preferred terms are summarized as rates for each treatment group in the study and are analyzed by statistical assessments of the difference in rates between treatment groups, usually in the form of P values from significance tests such as the Fisher exact test. This article outlines novel methods of analyzing adverse events and diseusses the concepts derived from the disciplines of computer science and statistics to implement them.

BACKGROUND AND RATIONALE

In the routine analysis of adverse events from clinical trials, clinical researchers typically focus on the rate of a single adverse event and seldom attempt to determine the rate of concurrence of various adverse events in patients. In examining and diagnosing patients, however, it is standard practice for physicians to think of clinical signs and symptoms as a constellation within the same patient, as an aid to diagnosing the underlying disease, or, rarely, as the hallmark of a newly emerging disease. We maintain that a conceptual gap exists between the univariate reporting of adverse events in clinical trials and the physician’s conception of medical signs and symptoms as a constellation of events to be studied. Standard univariate reports of adverse events do not draw on this physician perspective in their interpretation, isolating the consideration of one adverse event from another in the process of safety monitoring and review. We propose a new method of analyzing adverse events by enumerating, and determining the importance of, clinical syndromes and adverse event constellations.