Review of clinical activity by microbiologists.

A data form was devised and used to collect information on clinical cases involving a microbiologist. From the results a relational database management system was created. Of a total of 280 interventions, 137 (49%) were proactive, and in 118 (86%) of these cases the advice given was accepted. The majority of the patients in these cases showed subsequent improvement. Of all the interventions, the given advice was acted upon in 235 (84%), in 22 (8%) it was not and for the remainder this information was not available. This study was a simple method of gaining information on the clinical involvement of the microbiology department of a large city hospital. It provides a reference point from which further research and audit can be based.     

Provision of information and advice in cardiovascular care: clinical performance of general practitioners

The aim of this study was to assess the provision of information and advice by general practitioners (GPs) with respect to patients with hypertension, hypercholesterolaemia, or cardiovascular disease. The study relied on the prospective recording of patient encounters by GPs. Performance indicators were selected from the Dutch national guidelines for general practice. The GPs (n=195) completed 5330 encounter forms. High levels of performance were found with regard to advice on smoking cessation and the provision of information (e.g. information about alarm symptoms or the aim of treatment). Low levels of performance were found with regard to advice on salt consumption, alcohol consumption, weight reduction and physical exercise for patients with hypertension. Discussion of compliance with the therapy in case of hypercholesterolaemia, advice on physical exercise in case of angina pectoris and advice on foot care in case of peripheral arterial disease also showed a substantial gap between recommended and actual care. Performance rates varied considerably across GPs. The patient and GP characteristics examined in this study contributed very little to the clinical performance.     

The expectations for the third generation clinical laboratories in Japan

The author expressed his hopes and expectations for third generation clinical laboratory schemes or systems in Japan. The history of development of the clinical laboratory in Japan can be classified three generations after the Second World War, the first generation (1945-1975), the second generation (1970-2005) and the third generation (2001-). The third generation clinical laboratory can be called "the clinical laboratory for the 21st century". The author advised some suggestions for the clinical laboratory for the 21st century. The main advice of the author is as follows: 1) The necessity of professional physicians of clinical laboratory medicine in hospitals. 2) The necessity of standardization and holding nationwide common reference values of main clinical laboratory tests. 3) The realization of a network of high-grade laboratory tests between all clinical laboratory divisions of the national university hospitals.     

Improving recommendations for genomic medicine: building an evolutionary process from clinical practice advisory documents to guidelines

Genomic sequencing and multigene panel tests are moving rapidly into clinical practice for a range of indications, but the evidence to guide appropriate use is currently limited. Well-crafted advice is needed to reduce unjustified practice variation, minimize risk of error and harm to patients, and encourage best practices. In the absence of definitive evidence, provisional advice can be helpful if it clarifies the potential benefits and risks of different courses of action and identifies the knowledge gaps most important to address in future research. This paper proposes an evolutionary process starting with clinical practice advisory documents (CPADs) and culminating in clinical practice guidelines (CPGs), using two case examples to illustrate the need for this process. When evidence is limited, CPADs can clarify current practice options and identify key knowledge gaps. Added evidence can then support updates to the CPADs over time. Ultimately CPADs can provide the foundation for definitive CPGs as the evidence base matures. This approach addresses an important challenge in genomics and may be applicable to other fields in which technology and practice are outpacing evidence generation.     

Making the most of video recorded clinical encounters: Optimizing impact and productivity through interdisciplinary teamwork

Patient-clinician interactions are central to technical and interpersonal processes of medical care. Video recordings of these interactions provide a rich source of data and a stable record that allows for repeated viewing and analysis. Collecting video recordings requires navigating ethical and feasibility constraints; further, realizing the potential of video requires specialized research skills. Interdisciplinary collaborations involving practitioners, medical educators, and social scientists are needed to provide the clinical perspectives, methodological expertise, and capacity needed to make collecting video worthwhile. Such collaboration ensures that research questions will be based on scholarship from the social sciences, resonate with practice, and produce results that fit educational needs. However, the literature lacks suggested practices for building and sustaining interdisciplinary research collaborations involving video data. In this paper, we provide concrete advice based on our experience collecting and analyzing a single set of video-recorded clinical encounters and non-video data, which have so far yielded nine distinct studies. We present the research process, timeline, and advice based on our experience with interdisciplinary collaboration. We found that integrating disciplines and traditions required patience, compromise, and mutual respect; learning from each other enhanced our enjoyment of the process, our productivity, and the clinical relevance of our research.     

临床护理路径在介人治疗股骨头无菌性坏死的应用与探讨

目的建立完善的介入治疗股骨头无菌性坏死的临床护理路径，使患者手术前后的医疗护理服务规范化。方法按入院先后顺序随机将60例患者分为对照组和实验组，各30例。对照组采用按常规医嘱进行护理，实验组按临床护理路径方法制定围手术期间护理路线图进行护理，观察2组患者掌握股骨头无菌性坏死相关知识和相关技能、平均住院时间、平均住院费用、术后并发症和患者满意度有无差异。结果2组患者所获得的结果差异具有统计学意义（P〈0．01）。结论临床护理路径在介入治疗股骨头无菌性坏死的应用可有效提高护士的工作质量和患者的遵医行为，从而提高了医院的社会效益和经济效益。     

Decision support tools for clinical trial design

Many published clinical trials are poorly designed, suggesting that the protocol was incomplete, disorganised, or contained errors. This fact motivated the development of a suite of decision support tools for the design of randomised controlled clinical trials. In this paper we describe these tools, discussing both underlying theoretical issues and usage of the tools. The core tool--Design-a-Trial (DaT)--critiques data entered so as to guide design of a scientifically and ethically sound trial. DaT outputs a text protocol describing the trial, and a corresponding symbolic representation. Linked to DaT is a tool for authoring plans that form part of the trial. A key feature of this tool is the provision of macros for describing commonly occurring plan constructs. We describe another linked tool which generates solutions to Prolog queries requesting advice on how a plan should be revised so as to comply with safety and efficacy requirements. The user is able to navigate a path through the solution search space by interacting with natural language representations of the Prolog sub-goals. This provides the flexibility to generate useful and informative partial solutions, symbolic and textual, for inclusion in the symbolic plan representation and protocol document, respectively.     

Some fundamental points concerning the clinical aspects of desensitization

Continued exposure of target cells to a hormonal agonist frequently leads to a blunted response to that agonist. This process has been termed desensitization, refractoriness, tolerance or tachyphylaxis. The receptor involved in case of beta-sympathomimetics is the beta-adrenergic receptor. When the clinical aspects of beta-adrenergic receptor desensitization are considered, a number of points need serious attention: 1) the route of administration of the drug and the concentration of the drug reached at the receptor site; 2) other factors which may cause reduced responsiveness of the beta-adrenergic receptor besides beta-sympathomimetics and interfere with this process; 3) the different cell-types which are studied and thought to be representative for processes taking place at lung tissue level; 4) the in vivo parameter(s) chosen to describe desensitization; 5) the difference between normal and asthmatic subjects; 6) the mechanism behind desensitization. The paper concerns a review of these points. Since the clinical findings with respect to the induction of desensitization by beta-sympathomimetics are rather controversial, the therapeutic advice should be: use it with caution.     

Systematization of clinical laboratory--some problems caused from specimen transport through laboratory reports]

Through error and trials we have designed an ideal system for the clinical laboratory. Truly, it has been a very difficult task requiring our long-term experience working in the clinical laboratory. For example, if we purchase new examination equipment without any consideration or if we decide what type of equipment to introduce according to the common advice of the purchase committee of the hospital or the medical school, then we cannot design an ideal system of laboratory examinations and are forced to invest a large sum of money in vain. Moreover, the use of innumerable examination containers or test tubes which are disposable, can become a financial burden to the hospital. We have been trying to design a system of laboratory automation for more than ten years and have been successful in designing not only a specimen transport system using conveyer-belts but also various kinds of examination robotic systems. This report describes our own examples of designing a system of laboratory automation.     

The diagnostic MRCP examination: overcoming technical challenges to ensure clinical success

The magnetic resonance cholangiopancreatography (MRCP) examination has all but replaced the diagnostic endoscopic retrograde cholangiopancreatography (ERCP) examination for imaging the biliary tree and pancreatic ducts in many practical aspects of the clinical setting. Despite this increase in popularity, many magnetic resonance imaging (MRI) radiographers still find aspects of the MRCP examination quite challenging. The aim of this tutorial paper is to provide useful technical advice on how to overcome such perceived challenges and thus produce a successful diagnostic MRCP examination. This paper will be of interest to novice MRI radiographers who are at the beginning of their learning curve in MRCP examination. Other MRI radiographers who are interested in practical tips for protocol variations may also find the paper useful.     

可降解神经套接管制备及临床试验流程专家共识

周围神经损伤是一种常见临床疾病,损伤后的有效修复是减少损伤并发症、改善预后的重要措施.临床上治疗单纯横断伤或微小缺损的神经损伤多采用显微外科对位缝合方式吻合神经断端,但临床修复效果难达到预期.基于周围神经选择性再生学说,研究者发现小间隙套接缝合的修复效果明显好于传统的神经外膜缝合方法.因此,研发一种用来桥接周围神经断端...     

Which clinical practice guidelines for depression? An overview for busy practitioners.

BACKGROUND: Many policy and research documents on the treatment of depression in primary care suggest that general practitioners (GPs) should make use of clinical guidelines. AIM: To describe the content of peer-reviewed guidelines for the detection and treatment of depression in primary care and help GPs identify the one most useful to their own needs. METHOD: Guidelines were evaluated by an explicit method using the Institute of Medicine assessment instrument and according to six key clinical management questions identified as important by GPs and psychiatrists. RESULTS: Only five (30%) of the published guidelines identified met all the pre-defined inclusion criteria. Total scores for development process and content ranged from 54% to 82%. Validity scores ranged from 52% to 88%. No guideline answered all the key questions identified by clinicians. CONCLUSIONS: Only two guidelines conform to the quality standard of a clinical practice guideline. One covers all aspects of detection and management of depression in primary care but gives no advice on first-line choice of antidepressant, while the other focuses only on medication and fails to explore problems of case detection or to consider non-pharmacological treatments. However, taken together they do cover most of the key clinical issues in a reliable and valid manner. The identified guidelines vary considerably in both utility and clinical applicability.     

Opportunistic health promotion: quantity or quality?

A cohort of 130 working class mothers has been studied in depth over five years to quantify the extent of recording and counselling of lifestyle problems by general practitioners and their staff. Clinical records and mothers'' personal accounts at two home interviews five years apart provide the data for this work. Fifty-nine per cent of women had one or more aspects of lifestyle recorded in their records, the commonest being smoking habits. Despite this evidence for good coverage of smokers in the population, alcohol and exercise problems were under-recorded. Clinical records only included details of advice given and follow-up plans for lifestyle problems in 40% of patients'' records yet the women themselves remembered advice being given in 48% of cases. An analysis of the womens'' accounts in conjunction with the clinical records revealed that over three quarters of those receiving advice remembered it several years later. The primary care team was most likely to target advice and plans on women who were heavy smokers and very obese. This study shows that clinical records underestimate the amount of lifestyle counselling which is conducted in general practice and that a surprising number of working class women remember and act on the advice from their doctors. The implications for clinical recording of lifestyle factors are discussed.     

Plant food allergies: a suggested approach to allergen-resolved diagnosis in the clinical practice by identifying easily available sensitization markers

BACKGROUND: Molecular biology techniques have led to the identification of a number of allergens in vegetable foods, but due to the lack of purified food proteins for routine diagnostic use, the detection of sensitizing allergens remains a nearly impossible task in most clinical settings. The allergen-resolved diagnosis of food allergy is essential because each plant-derived food may contain a number of different allergens showing different physical/chemical characteristics that strongly influence the clinical expression of allergy; moreover, many allergens may cross-react with homologue proteins present in botanically unrelated vegetable foods. OBJECTIVE: Through a review of the available literature, this study aimed to detect "markers" of sensitization to specific plant food allergens that are easily accessible in the clinical practice. RESULTS: There are several "markers" of sensitization to different allergenic proteins in vegetable foods that can be helpful in the clinical practice. Specific algorithms for patients allergic to Rosaceae and to tree nuts were built. CONCLUSION: Clinical allergologists lacking the assistance of an advanced molecular biology lab may take advantage of some specific clinical data as well as of some "markers" in the difficult task of correctly diagnosing patients with plant food allergy and to provide them the best preventive advice.     

Measuring nonverbal behavior in clinical interactions: A pragmatic guide

Objective

Understanding nonverbal behavior is key to the research, teaching, and practice of clinical communication. However, the measurement of nonverbal behavior can be complex and time-intensive. There are many decisions to make and factors to consider when coding nonverbal behaviors.

Retrospective evaluation of a decision support system for controlled mechanical ventilation

Management of mechanical ventilation in intensive care patients is complicated by conflicting clinical goals. Decision support systems (DSS) may support clinicians in finding the correct balance. The objective of this study was to evaluate a computerized model-based DSS for its advice on inspired oxygen fraction, tidal volume and respiratory frequency. The DSS was retrospectively evaluated in 16 intensive care patient cases, with physiological models fitted to the retrospective data and then used to simulate patient response to changes in therapy. Sensitivity of the DSS’s advice to variations in cardiac output (CO) was evaluated. Compared to the baseline ventilator settings set as part of routine clinical care, the system suggested lower tidal volumes and inspired oxygen fraction, but higher frequency, with all suggestions and the model simulated outcome comparing well with the respiratory goals of the Acute Respiratory Distress Syndrome Network from 2000. Changes in advice with CO variation of about 20% were negligible except in cases of high oxygen consumption. Results suggest that the DSS provides clinically relevant and rational advice on therapy in agreement with current ‘best practice’, and that the advice is robust to variation in CO.     

Computer-interpretable clinical guidelines: A methodological review

Clinical practice guidelines (CPGs) aim to improve the quality of care, reduce unjustified practice variations and reduce healthcare costs. In order for them to be effective, clinical guidelines need to be integrated with the care flow and provide patient-specific advice when and where needed. Hence, their formalization as computer-interpretable guidelines (CIGs) makes it possible to develop CIG-based decision-support systems (DSSs), which have a better chance of impacting clinician behavior than narrative guidelines. This paper reviews the literature on CIG-related methodologies since the inception of CIGs, while focusing and drawing themes for classifying CIG research from CIG-related publications in the Journal of Biomedical Informatics (JBI). The themes span the entire life-cycle of CIG development and include: knowledge acquisition and specification for improved CIG design, including (1) CIG modeling languages and (2) CIG acquisition and specification methodologies, (3) integration of CIGs with electronic health records (EHRs) and organizational workflow, (4) CIG validation and verification, (5) CIG execution engines and supportive tools, (6) exception handling in CIGs, (7) CIG maintenance, including analyzing clinician’s compliance to CIG recommendations and CIG versioning and evolution, and finally (8) CIG sharing. I examine the temporal trends in CIG-related research and discuss additional themes that were not identified in JBI papers, including existing themes such as overcoming implementation barriers, modeling clinical goals, and temporal expressions, as well as futuristic themes, such as patient-centric CIGs and distributed CIGs.     

Research into the role of fertility nurses for the development of guidelines for clinical practice

The Fertility Nurses Group (FNG) celebrates its 10th anniversary this year after a decade of many exciting developments. The pioneers of the FNG believed that professional advice and support were needed for nurses developing their roles within a dynamic and rapidly advancing field with new clinical and scientific techniques which also brought challenging moral dilemmas. A specialist membership group was therefore established with the Royal College of Nursing (RCN). One of the first tasks was to investigate the educational requirements of infertility nurses and assess the professional and ethical issues raised by nurses caring for infertile patients. The results of this were published in the first 'professional survey'. A decade later the FNG undertook further research into the scope of clinical practice and the working conditions of its membership. Members of the group directly involved with the provision of fertility treatment, from ovulation induction to in-vitro fertilization, were surveyed. A questionnaire was circulated which aimed to: (i) assess the roles, skill and working patterns of nurses working in infertility units; (ii) identify the training needs of nurses and the management and educational provision required to support this. Further research will also be undertaken to explore issues related to the extended role of fertility nurses and its relevance to the UK Central Council guidelines on clinical nurse specialists and advance nurse practitioners. The results of the forthcoming research studies will provide data to assist with: (i) the development of guidelines for clinical practice; and (ii) continued development of appropriate educational programmes for fertility nurses.      

Interface design principles for usable decision support: A targeted review of best practices for clinical prescribing interventions

Developing effective clinical decision support (CDS) systems for the highly complex and dynamic domain of clinical medicine is a serious challenge for designers. Poor usability is one of the core barriers to adoption and a deterrent to its routine use. We reviewed reports describing system implementation efforts and collected best available design conventions, procedures, practices and lessons learned in order to provide developers a short compendium of design goals and recommended principles. This targeted review is focused on CDS related to medication prescribing.Published reports suggest that important principles include consistency of design concepts across networked systems, use of appropriate visual representation of clinical data, use of controlled terminology, presenting advice at the time and place of decision making and matching the most appropriate CDS interventions to clinical goals.Specificity and contextual relevance can be increased by periodic review of trigger rules, analysis of performance logs and maintenance of accurate allergy, problem and medication lists in health records in order to help avoid excessive alerting.Developers need to adopt design practices that include user-centered, iterative design and common standards based on human–computer interaction (HCI) research methods rooted in ethnography and cognitive science. Suggestions outlined in this report may help clarify the goals of optimal CDS design but larger national initiatives are needed for systematic application of human factors in health information technology (HIT) development. Appropriate design strategies are essential for developing meaningful decision support systems that meet the grand challenges of high-quality healthcare.