Use of a Personal Digital Assistant for Managing Antibiotic Prescribing for Outpatient Respiratory Tract Infections in Rural Communities

ObjectiveTo assess the acceptability and usage of a standalone personal digital assistant (PDA)-based clinical decision-support system (CDSS) for the diagnosis and management of acute respiratory tract infections (RTIs) in the outpatient setting.DesignObservational study performed as part of a larger randomized trial in six rural communities in Utah and Idaho from January 2002 to March 2004. Ninety-nine primary care providers received a PDA-based CDSS for use at the point-of-care, and were asked to use the tool with at least 200 patients with suspected RTIs.MeasurementsClinical data were collected electronically from the devices at periodic intervals. Providers also completed an exit questionnaire at the end of the study period.ResultsProviders logged 14,393 cases using the CDSS, the majority of which (n=7624; 53%) were from family practitioners. Overall adherence with CDSS recommendations for the five most common diagnoses (pharyngitis, otitis media, sinusitis, bronchitis, and upper respiratory tract infection) was 82%. When antibiotics were prescribed (53% of cases), adherence with the CDSS-recommended antibiotic was high (76%). By logistic regression analysis, the odds of adherence with CDSS recommendations increased significantly with each ten cases completed (P=0.001). Questionnaire respondents believed the CDSS was easy to use, and most (44/65; 68%) did not believe it increased their encounter time with patients, regardless of prior experience with PDAs.ConclusionA standalone PDA-based CDSS for acute RTIs used at the point-of-care can encourage better outpatient antimicrobial prescribing practices and easily gather a rich set of clinical data.     

Clinical decision support system,using expert consensus-derived logic and natural language processing,decreased sedation-type order errors for patients undergoing endoscopy

ObjectiveDetermination of appropriate endoscopy sedation strategy is an important preprocedural consideration. To address manual workflow gaps that lead to sedation-type order errors at our institution, we designed and implemented a clinical decision support system (CDSS) to review orders for patients undergoing outpatient endoscopy.Materials and MethodsThe CDSS was developed and implemented by an expert panel using an agile approach. The CDSS queried patient-specific historical endoscopy records and applied expert consensus-derived logic and natural language processing to identify possible sedation order errors for human review. A retrospective analysis was conducted to evaluate impact, comparing 4-month pre-pilot and 12-month pilot periods.Results22 755 endoscopy cases were included (pre-pilot 6434 cases, pilot 16 321 cases). The CDSS decreased the sedation-type order error rate on day of endoscopy (pre-pilot 0.39%, pilot 0.037%, Odds Ratio = 0.094, P-value < 1e-8). There was no difference in background prevalence of erroneous orders (pre-pilot 0.39%, pilot 0.34%, P = .54).DiscussionAt our institution, low prevalence and high volume of cases prevented routine manual review to verify sedation order appropriateness. Using a cohort-enrichment strategy, a CDSS was able to reduce number of chart reviews needed per sedation-order error from 296.7 to 3.5, allowing for integration into the existing workflow to intercept rare but important ordering errors.ConclusionA workflow-integrated CDSS with expert consensus-derived logic rules and natural language processing significantly reduced endoscopy sedation-type order errors on day of endoscopy at our institution.     

Electronic clinical decision support systems attitudes and barriers to use in the oncology setting

Background

There is little evidence regarding attitudes to clinical decision support systems (CDSS) in oncology.

Aims

We examined the current usage, awareness, and concerns of Irish medical oncologists and oncology pharmacists in this area.

Methods

A questionnaire was sent to 27 medical oncologists and 34 oncology pharmacists, identified through professional interest groups. Respondents ranked concerns regarding their use of a CDSS on a scale from 1 to 4, with 4 being most important.

Results

Overall, 67% (41/61) responded, 48% (13/27) of oncologists and 82% (28/34) of pharmacists surveyed. Concerns included ??difficulty defining complex clinical situations with a set of rules?? (mean?±?SD) (3.2?±?0.9), ??ensuring evidence base is up to date and relevant?? (3.2?±?0.9) and ??lack of clinically relevant suggestions?? (2.9?±?0.9). Ninety-three percent reported using a CDSS but 54% were unaware of this.

Conclusion

While there are benefits to using a CDSS, concerns must be addressed through user education. This may be a starting point for a user-centred design approach to the development of future local systems through a consultative process.     

Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings

Objective

To synthesize the literature on clinical decision-support systems'' (CDSS) impact on healthcare practitioner performance and patient outcomes.

Design

Literature search on Medline, Embase, Inspec, Cinahl, Cochrane/Dare and analysis of high-quality systematic reviews (SRs) on CDSS in hospital settings. Two-stage inclusion procedure: (1) selection of publications on predefined inclusion criteria; (2) independent methodological assessment of preincluded SRs by the 11-item measurement tool, AMSTAR. Inclusion of SRs with AMSTAR score 9 or above. SRs were thereafter rated on level of evidence. Each stage was performed by two independent reviewers.

Results

17 out of 35 preincluded SRs were of high methodological quality and further analyzed. Evidence that CDSS significantly impacted practitioner performance was found in 52 out of 91 unique studies of the 16 SRs examining this effect (57%). Only 25 out of 82 unique studies of the 16 SRs reported evidence that CDSS positively impacted patient outcomes (30%).

Conclusions

Few studies have found any benefits on patient outcomes, though many of these have been too small in sample size or too short in time to reveal clinically important effects. There is significant evidence that CDSS can positively impact healthcare providers'' performance with drug ordering and preventive care reminder systems as most clear examples. These outcomes may be explained by the fact that these types of CDSS require a minimum of patient data that are largely available before the advice is (to be) generated: at the time clinicians make the decisions.     

直肠癌60例手术治疗体会

目的 对直肠癌术式的选择及手术治疗过程中对膀胱和性功能的损伤两个主要的难点进行探讨.方法 回顾分析我院2005～2007年行外科手术治疗的60例直肠癌患者的病例资料,分析不同分期与不同手术方式的治疗效果.结果 直肠癌患者5年生存率Duke A、B、C期分别为97.0％,55.0％,20.0％,下段癌吻合术后发生吻合口漏1例,排尿功能障碍5例,男性勃起功能障碍6例,射精功能障碍5例.结论 中下段直肠癌保肛手术疗效确切,手术过程中应用PANP（pelvic autonomic nerve preservation）能明显降低手术对膀胱和性功能的损伤.     

Short-term outcomes of neoadjuvant chemotherapy with capecitabine plus oxaliplatin for patients with locally advanced rectal cancer followed by total or tumor-specific mesorectal excision with or without lateral pelvic lymph node dissection

Background: The standard strategy in Japan for locally advanced rectal cancer is total mesorectal excision plus adjuvant chemotherapy. However, large tumors significantly restrict pelvic manipulation of the distal side of the tumor during surgery; therefore, from an oncological point of view, it is better to shrink the tumor as much as possible preoperatively to optimize the circumferential resection margin. In recent years, advances in systemic chemotherapy have significantly improved the tumor reduction effect, enabling such drug therapy prior to surgery for locally advanced rectal cancer. We herein retrospectively evaluated the clinical, short-term outcomes of patients treated by neoadjuvant chemotherapy (NAC) using capecitabin and oxaliplatin (CAPOX), focusing on overall safety as well as clinical and pathological staging responses to NAC.Methods: We applied the preoperative chemotherapy protocol to T3-4, any N, M0 or M1a (with resectable metastases) (UICC 8^th) Ra/Rb rectal cancers. The chemotherapy regimen consisted of four cycles of CAPOX. After NAC, curative intent surgery with total mesorectal excision/tumor-specific mesorectal excision with/without metastasectomy was performed. Adverse effects (AEs) and compliance with NAC, surgical complications, clinical and pathological staging were evaluated. All patients undergoing the protocol between January 2017 and June 2021 at Fukushima Medical University were enrolled.Results: Twenty cases were enrolled. No severe AEs were observed either preoperatively or perioperatively. Preoperative assessment of NAC showed no cases of progressive disease (PD). Radical resection was achieved in all cases. Histological therapeutic grading after NAC revealed one grade 3, four grade 2, three grade 1b, eleven grade 1a and one grade 0 among all cases.Conclusion: This study suggests that NAC for locally advanced rectal cancer is likely to be acceptable because there were no severe AEs pre- or perioperatively, radical resection was achieved in all cases, and there were no cases of PD.     

高分辨率MRI对直肠癌TN分期及肠壁外脉管侵犯的诊断价值

目的 探究高分辨率磁共振成像（MRI）对直肠癌TN分期及肠壁外脉管侵犯的诊断价值。方法 回顾分析2020年1月至2020年12月阜阳市人民医院收入院的74例直肠癌患者临床资料，所有患者均接受了高分辨率MRI检测。以病理诊断直肠癌TN分期及肠壁外脉管侵犯为金标准，比较高分辨率MRI诊断直肠癌T分期、N分期及肠壁外脉管侵犯与病理诊断的差异，采用Kappa一致性检验分析高分辨率MRI与病理检测对直肠癌TN分期及肠壁外脉管侵犯诊断结果的一致性。结果 高分辨率MRI诊断直肠癌T分期、N分期及肠壁外脉管侵犯准确性低于与病理诊断，且差异有统计学意义（P<0.05）。高分辨率MRI序列诊断直肠癌T2期、T3期、T4期的一致性Kappa值分别为0.612、0.516和0.750，诊断直肠癌N0期、N1期、N2期的一致性Kappa值分别为0.437、0.544和0.448，检测肠壁外脉管侵犯的一致性Kappa值为0.634。结论 高分辨MRI用于直肠癌TN分期及肠壁外脉管侵犯的诊断，诊断效能尚可，与病理诊断一致性中等。     

miR-23a调控ESRP1干预直肠癌细胞增殖和凋亡

目的 分析微小RNA-23a （microRNAs-23a,miR-23a）在直肠癌组织及细胞系中的相对表达水平,以及miR-23a对直肠癌细胞增殖和凋亡的作用,并分析其可能作用机制。方法 采用qRT-PCR检测miR-23a在36例直肠癌组织和癌旁正常组织中的表达水平;利用qRT-PCR检测miR-23a在直肠癌SW480细胞及人正常结肠上皮细胞株NCM460中的表达;合成miR-23a抑制剂（inhibitor） RNA片段和抑制剂阴性对照RNA片段（inhibitor negative control,inhibitor NC）,并将其分别转染至SW480细胞后,通过CCK-8法检测miR-23a inhibitor转染SW480细胞后对细胞增殖的影响;流式细胞术检测转染后细胞凋亡率;Western blot法检测上皮剪接调节蛋白1（epithelial splicing regulatory protein 1,ESRPl）蛋白在SW480细胞中的表达水平;构建野生型pGL3-ESRP1-3''UTR （wt-pGL3-ESRP1-3''UTR）或突变型pGL3-ESRP1-3''UTR （mut-pGL3-ESRP1-3''UTR）质粒,HEK293和SW480细胞经上述质粒分别与miR-23a inhibitor或inhibitor NC共转染后测定双荧光素酶活性。结果 与癌旁正常组织相比较,miR-23a在直肠癌组织中的相对表达水平明显上调,差异有统计学意义（P=0.000）;与NCM460细胞相比较,miR-23a在SW480细胞中的表达量显著上调,差异有统计学意义（P=0.000）;SW480细胞转染miR-23a inhibitor后,细胞增殖较inhibitor NC组下降35.54%±5.27%,两组结果差异有统计学意义（P=0.000）;转染miR-23a inhibitor后SW480细胞早期凋亡率明显高于inhibitor NC组（P=0.000）;荧光素酶报告基因结果表明ESRP1是miR-23a的直接靶基因;SW480细胞转染inhibitor NC后对ESRP1蛋白表达无明显影响,而转染miR-23a inhibitor至SW480细胞后ESRP1蛋白表达水平明显升高。结论 miR-23a在直肠癌组织和细胞系中的表达均显著升高,miR-23a可通过下游靶基因ESRP1从而调控直肠癌细胞增殖和凋亡。     

Accuracy of a computerized clinical decision-support system for asthma assessment and management

Objective

To evaluate the accuracy of a computerized clinical decision-support system (CDSS) designed to support assessment and management of pediatric asthma in a subspecialty clinic.

Design

Cohort study of all asthma visits to pediatric pulmonology from January to December, 2009.

Measurements

CDSS and physician assessments of asthma severity, control, and treatment step.

Results

Both the clinician and the computerized CDSS generated assessments of asthma control in 767/1032 (74.3%) return patients, assessments of asthma severity in 100/167 (59.9%) new patients, and recommendations for treatment step in 66/167 (39.5%) new patients. Clinicians agreed with the CDSS in 543/767 (70.8%) of control assessments, 37/100 (37%) of severity assessments, and 19/66 (29%) of step recommendations. External review classified 72% of control disagreements (21% of all control assessments), 56% of severity disagreements (37% of all severity assessments), and 76% of step disagreements (54% of all step recommendations) as CDSS errors. The remaining disagreements resulted from pulmonologist error or ambiguous guidelines. Many CDSS flaws, such as attributing all ‘cough’ to asthma, were easily remediable. Pediatric pulmonologists failed to follow guidelines in 8% of return visits and 18% of new visits.

Limitations

The authors relied on chart notes to determine clinical reasoning. Physicians may have changed their assessments after seeing CDSS recommendations.

Conclusions

A computerized CDSS performed relatively accurately compared to clinicians for assessment of asthma control but was inaccurate for treatment. Pediatric pulmonologists failed to follow guideline-based care in a small proportion of patients.     

Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer

CONTEXT: Multiple treatment options are available for men with prostate cancer, but therapeutic recommendations may differ depending on the type of specialist they consult. OBJECTIVE: To define and contrast the distribution of management recommendations by urologists and radiation oncologists for a spectrum of men with prostate cancer. DESIGN, SETTING, AND PARTICIPANTS: Mail survey sent in 1998 to a random sample of physicians in the United States, who were listed as urologists (response rate 64%, n=504) and radiation oncologists (response rate 76%, n=559) in the American Medical Association Registry of Physicians and practicing at least 20 hours per week. MAIN OUTCOME MEASURE: Questionnaire addressing beliefs and practices regarding prostate cancer management. RESULTS: Forty-three percent of radiation oncologists vs 16% of urologists would recommend routine prostate-specific antigen testing for men aged 80 years and older. For men with moderately differentiated, clinically localized cancers, and a more than 10-year life expectancy, 93% of urologists chose radical prostatectomy as the preferred treatment option, while 72% of radiation oncologists believed surgery and external beam radiotherapy were equivalent treatments. For most tumor grades and prostate-specific antigen levels, both specialty groups were significantly more likely to recommend the treatment in their specialty than the other treatment. Both groups reported giving patients similar estimates of the risks of complications due to surgery and radiation. Neither group favored watchful waiting in their treatment management except for a subset of men with life expectancies of less than 10 years and cancers with very favorable prognoses (Gleason score of 3 or 4 and prostate-specific antigen level 相似文献   

Assessing the Sensibility of Two Clinical Decision Support Systems

Clinicians in Emergency Medicine (EM) are increasingly exposed to guidelines and treatment recommendations. To help access and recall these recommendations, electronic Clinical Decision Support Systems (CDSS) have been developed. This study examined the use and sensibility of two CDSS designed for emergency physicians. CDDS for community acquired pneumonia (CAP) and neutropenic fever (NF) were developed by multidisciplinary teams and have been accessed via an intranet-based homepage (eCPG) for several years. Sensibility is a term coined by Feinstein that describes common sense aspects of a survey instrument. It was modified by emergency researchers to include four main headings: (1) Appropriateness; (2) Objectivity; (3) Content; and (4) Discriminative Power. Sensibility surveys were developed using an iterative approach for both the CAP and NF CDSS and distributed to all 25 emergency physicians at one Canadian site. The overall response rate was 88%. Respondents were 88% male and 83% were less than 40; all were attending EM physicians with specialty designations. A number reported never having used the CAP (21%) or NF (33%) CDSS; 54% (CAP) and 21% (NF) of respondents had used the respective CDSS less than 10 times. Overall, both CDSS were rated highly by users with a mean response of 4.95 (SD 0.56) for CAP and 5.62 (SD 0.62) for NF on a seven-point Likert scale. The majority or respondents (CAP 59%, NF 80%) felt that the NF CDSS was more likely than the CAP CDSS to decrease the chances of making a medical error in medication dose, antibiotic choice or patient disposition (4.61 vs. 5.81, p=0.008). Despite being in place for several years, CDSS for CAP and NF are not used by all EM clinicians. Users were generally satisfied with the CDSS and felt that the NF was more likely than the CAP CDSS to decrease medical errors. Additional research is required to determine the barriers to CDSS use.     

Combined Spline and B-spline for an Improved Automatic Skin Lesion Segmentation in Dermoscopic Images Using Optimal Color Channel

Globally one in twelve people have the Hepatitis B or Hepatitis C virus. Diagnosis and treatment of this disease is guided by liver biopsies where a small amount of tissue is removed by a surgeon and examined by a pathologist to determine the fibrosis stage from F₀ (no damage) to F₄ (cirrhosis). Biopsies are costly and carry some risk for the patient. Non-invasive techniques for determining fibrosis stage have been developed and evaluated since 2003. Non-invasive methods have utilized serum markers, imaging test, and genetic studies. The accuracy of these non-invasive techniques has not achieved sufficient acceptance and so the invasive biopsy is still considered the gold standard. Clinical decision support systems (CDSS) use decision support system theory and technology to assist clinicians in the evaluation and treatment process. Using historical clinical data and the relationship processed by Artificial Intelligence (AI) techniques to aid physicians in their decision making process is the goal of CDSS. The CDSS provides a large number of medical support functions to help clinicians make the most reasonable diagnosis and choose the best treatment measures. This paper applies four artificial intelligence predictive techniques to publicly available data on 424 Hepatitis B and Hepatitis C patients. Demographic and standard serum markers are utilized to predict fibrosis stage and compare these predictions to known biopsy results. A final decision tree evaluation is applied to make a final prediction. We have also developed a publically available web application that can be used as a prototype for presenting AI predictive results in a CDSS environment based on these models. This technique along with others could mitigate the need for some liver biopsies in the more than 500 million Hepatitis B and C patients worldwide with additional validation and verification.     

Effect of modified Sinisan on anorectal manometry of the constipation predominant type of irritable bowel syndrome

Objective: To explore the mechanism in patients with irritable bowel syndrome (IBS) of the constipation predominant type and observe the therapeutic effects of Sinisan (SNS).Methods: Forty-seven IBS patients with the constipation predominant type were randomly divided into the treated group (n = 24) and the control group (n = 23). Another group of 22 healthy subjects was set up for healthy control. The treated group was treated with modified SNS, and the control group was treated with Cisapride, the therapeutic course for both groups was 8 weeks. The changes of symptom scoring and anorectal manometry (the anorectal resting pressure, anal tract systolic pressure, anal tract diastolic pressure, rectal threshold feeling, maximal tolerance volume of rectum, and rectum compliance) of these two groups were recorded respectively and compared with each other.Results: Compared with the healthy control group, the rectal threshold feeling, maximal tolerance volume of rectum and rectal compliance of the treated groups got reduced significantly before treatment (P<0.05). After treatment, the symptom scoring, rectal threshold feeling and maximal tolerance volume of rectum were improved in both groups (P<0.05), and the improvement of the treated group was more significant than that of the control group(P<0. 01). The total effective rate and recurrence rate of the treated group were superior to those of the control group significantly (P<0.05,P<0.01).Conclusion: SNS has good effect on IBS of the constipation predominant type.     

Clinical decision support with automated text processing for cervical cancer screening

Objective

To develop a computerized clinical decision support system (CDSS) for cervical cancer screening that can interpret free-text Papanicolaou (Pap) reports.

Materials and Methods

The CDSS was constituted by two rulebases: the free-text rulebase for interpreting Pap reports and a guideline rulebase. The free-text rulebase was developed by analyzing a corpus of 49 293 Pap reports. The guideline rulebase was constructed using national cervical cancer screening guidelines. The CDSS accesses the electronic medical record (EMR) system to generate patient-specific recommendations. For evaluation, the screening recommendations made by the CDSS for 74 patients were reviewed by a physician.

Results and Discussion

Evaluation revealed that the CDSS outputs the optimal screening recommendations for 73 out of 74 test patients and it identified two cases for gynecology referral that were missed by the physician. The CDSS aided the physician to amend recommendations in six cases. The failure case was because human papillomavirus (HPV) testing was sometimes performed separately from the Pap test and these results were reported by a laboratory system that was not queried by the CDSS. Subsequently, the CDSS was upgraded to look up the HPV results missed earlier and it generated the optimal recommendations for all 74 test cases.

Limitations

Single institution and single expert study.

Conclusion

An accurate CDSS system could be constructed for cervical cancer screening given the standardized reporting of Pap tests and the availability of explicit guidelines. Overall, the study demonstrates that free text in the EMR can be effectively utilized through natural language processing to develop clinical decision support tools.     

直肠癌保肛手术与Miles术临床疗效的比较分析

目的：比较直肠癌保肛术与腹腔镜下Miles术的远期疗效。方法：对2007年9月~2008年2月24例直肠癌外科治疗进行回顾性分析。保肛手术组（对照组）12例,Miles术组（治疗组）12例。结果：运用腹腔镜下Miles手术的治疗组的术中平均出血量、术后平均排气时间、术后平均留置导尿时间和平均住院时间都比采用保肛术的对照组要短（P〈0.05）,显示出较好的临床疗效。结论：运用腹腔镜技术进行直肠癌Miles手术在理论和技术上是安全可行的,近期疗效好于传统开腹保肛手术,值得临床推广。     

Pattern of cancers in adolescent and young adults.: A 15-year retrospective study at King Fahad Hospital,Al-Madinah Al-Munawwarah,Saudi Arabia

Objectives:To evaluate the incidence and pattern of cancer in adolescents and young adults (AYAs) age group in Al-Madinah Al-Munawwarah region of Saudi Arabia.Methods:This retrospective histopathology-based study was conducted at a tertiary care center in Al-Madinah Al-Munawwarah, Saudi Arabia and comprised cases of cancers for 15 years between January 2006 and December 2020.Results:During the last 15-year period, 8,769 cases of cancers were diagnosed out of which 475 (5.4%) cases were registered in AYAs. Of these cases, 232 (48.8%) were males while 243 (51.2%) were females, with a male-to-female ratio of 0.9:1. The 3 most common cancer groups in the entire cohort were carcinomas (n=165; 34.7%), lymphomas (n=135; 28.4%), and leukemias (n=91; 19.2%). The most common sites in carcinomas were thyroid (n=60; 12.6%), breast (n=35; 7.4%), and gastrointestinal (n=18; 3.8%). The leading cancers in males were the lymphomas (n=74; 15.6%), leukemias (n=57; 12%), bone (n=21; 4.4%), and central nervous system (n=20; 4.2%), while in females, the most common cancers were the lymphomas (n=61; 12.8%), thyroid (n=40; 8.4%), breast (n=34; 7.2%), and leukemias (n=34; 7.2%).Conclusion:Our findings are in concordance with studies in national and international literature and we believe that our study provides a baseline tool for future population-targeted studies.     

61例结直肠癌并梗阻治疗体会

目的:探讨结直肠癌并梗阻的外科治疗方法及效果。方法:回顾性分析61例结直肠癌并梗阻行急诊手术治疗患者的临床资料,其中右半结肠癌梗阻18例,降结肠癌并梗阻16例,乙状结肠癌并梗阻21例,直肠癌并梗阻6例。结果:61例结直肠癌并梗阻均行手术治疗,其中一期切除吻合56例,术后吻合口漏2例,切口感染8例,切口裂开1例,所有病例均临床治愈。结论:结直肠癌并梗阻一期切除吻合是可行的,视术中梗阻情况选择合适的手术方式及术中正确的操作和围手术期处理,是本病治疗的关键。