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.     

Effects of computer-aided clinical decision support systems in improving antibiotic prescribing by primary care providers: a systematic review

Objective To assess the effectiveness of computer-aided clinical decision support systems (CDSS) in improving antibiotic prescribing in primary care.Methods A literature search utilizing Medline (via PubMed) and Embase (via Embase) was conducted up to November 2013. Randomized controlled trials (RCTs) and cluster randomized trials (CRTs) that evaluated the effects of CDSS aiming at improving antibiotic prescribing practice in an ambulatory primary care setting were included for review. Two investigators independently extracted data about study design and quality, participant characteristics, interventions, and outcomes.Results Seven studies (4 CRTs, 3 RCTs) met our inclusion criteria. All studies were performed in the USA. Proportions of eligible patient visits that triggered CDSS use varied substantially between intervention arms of studies (range 2.8–62.8%). Five out of seven trials showed marginal to moderate statistically significant effects of CDSS in improving antibiotic prescribing behavior. CDSS that automatically provided decision support were more likely to improve prescribing practice in contrast to systems that had to be actively initiated by healthcare providers.Conclusions CDSS show promising effectiveness in improving antibiotic prescribing behavior in primary care. Magnitude of effects compared to no intervention, appeared to be similar to other moderately effective single interventions directed at primary care providers. Additional research is warranted to determine CDSS characteristics crucial to triggering high adoption by providers as a perquisite of clinically relevant improvement of antibiotic prescribing.     

EFFICACY OF SUCRALFATE IN PREVENTING GASTROINTESTINAL SIDE EFFECTS OF NSAIDs

To find out the efficacy of sucralfate in preventing gastrointestinal side effects of non-steroidal anti-inflammatory drugs (NSAIDs) a prospective, randomised single blind study was conducted from 1989 to 1992. Patients with osteoarthritis, rheumatoid arthritis and other long standing painful conditions, who were expected to receive NSAIDs for over three months, were recruited into the study. All medicines were discontinued for a period of 10–15 days prior to initial endoscopic assessment. NSAID therapy was started and the patients were randomised to receive either placebo (group A) or sucralfate (group B) in addition. Patient were reassessed clinically every week and an endoscopic examination was repeated after 6–8 weeks of follow-up. A total of 176 patients were studied in group A (n=91) and group B (n=85). At the end of 8 weeks gastrointestinal symptoms were present in 30.6% and 26.4% patients of group A and B respectively. Endoscopic assessment showed superficial lesions in 36.5% and 18.7% while endoscopic ulcer in 2.4% and 1.1% patients of groups A and B respectively. Thus in patients receiving chronic NSAID therapy, simultaneous administration of sucralfate reduces the incidence of superficial gastric lesions but has no significant effect on symptoms or ulcer formation.KEY WORDS: Gastropathy, Sucralfate, Nonsteroidal anti-inflammatory drugs     

非甾体类抗炎药相关性胃黏膜损伤情况及替普瑞酮保护作用的随机对照观察

目的 评价长期服用非甾体类抗炎药(NSAID)引发胃黏膜的损伤情况,并探讨替普瑞酮对患者胃黏膜的保护作用.方法 收集长期服用NSAID且幽门螺杆菌(Hp)阴性患者108例,进行上消化道症状及胃镜评估.其中无溃疡患者92例,采用前瞻性随机对照研究,按是否服用替普瑞酮随机分为干预组(45例)与非干预组(47例),随访3个月后再次行上消化道症状及胃镜评估.在入选时及随访3个月后分别留取胃黏膜标本比较胃黏液层密度和环氧合酶(COX)表达水平.结果 在108例患者中发现消化性溃疡16例(14.8%),48例(44.4%)患者在胃镜下可观察到3处及以上黏膜糜烂灶.随访3个月后,替普瑞酮十预组患者胃黏膜损伤明显轻于非干预组(z=-4.96,P=0.000);胃黏液合成与分泌多于非干预组[阳性率66.7%(30/45)比13.3%(6/45),P=0.000];COX-1表达亦多于非干预组[31.1%(14/45)比6.7%(3/45),P=0.003];而COX-2表达则无变化[28.9%(13/45)比31.1%(14/45),P=0.82].结论 长期服用NSAID可致明显胃黏膜损伤;同时服用替普瑞酮可以降低胃黏膜损伤的发生,这可能与其促进黏液合成分泌和增加黏膜内COX-1表达有关.     

基于MDT的小班授课在普通外科住培带教中的应用研究

目的 本研究旨在评估多学科协作诊疗（multi-disciplinary treatment,MDT）模式结合小班授课对普通外科住培医师获取专业知识、掌握临床技能以及整体学习体验的影响。方法 选取2023年1至8月在普通外科轮转的2021级住培医师共60名,分为MDT教学组（n=30）和传统教学组（n=30）。所有住培医师在入科前进行一次理论测试及Mini-CEX技能考核,并比较两组入科前的理论测试成绩及Mini-CEX技能考核成绩。随后进行分组教学,其中MDT教学组针对胃肠道肿瘤采用MDT模式进行小班授课;传统教学组即以传统的“一带一”方式进行日常教学。住培轮转结束时,比较两组住培医师的理论考试成绩、技能操作考核情况以及对教学满意度的评价。采用SPSS 26.0进行统计学分析。结果 两组住培医师在入科前的理论考核成绩及Mini-CEX技能考核成绩差异均无统计学意义（P>0.05）。带教后,MDT教学组理论考试成绩（88.15±3.45）相对于传统教学组（72.25±4.36）更高,差异具有统计学意义（P<0.05）。MDT教学组Mini-CEX技能考核成绩（86.35±2.24）相对于传统教学组（76.28±3.92）更高,差异具有统计学意义（P<0.05）。问卷调查结果显示,MDT教学组住培医师对MDT小班授课教学满意度更高,对教学效果的评价也更好。结论 基于MDT模式的小班授课有利于提高普通外科住培医师胃肠道肿瘤的规范化培训质量,且住培医师的接受度更高,是住培教学有益的尝试。     

An evidence-based approach to prescribing NSAIDs in musculoskeletal disease: a Canadian consensus. Canadian NSAID Consensus Participants.

OBJECTIVE. To make recommendations for the long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) in primary care practice, particularly for patients at high risk for NSAID-induced complications. OPTIONS. The use of misoprostol to prevent gastrointestinal ulceration and other unwanted NSAIDs effects was considered. The role of cyclooxygenase-2 (COX-2) versus COX-1 inhibiting agents was also examined. OUTCOMES. Reduction of complications associated with long-term use of NSAIDs. EVIDENCE. Evidence was gathered in late 1995 from published research studies and reviews. Position papers were prepared by faculty and advisory board members and discussed at the Canadian NSAID Consensus Symposium in Cambridge, Ont., Jan. 26 and 27, 1996. VALUES. Recommendations were based on randomized, placebo-controlled clinical trials (level I evidence) and case-control studies (level II evidence) involving NSAID use when such evidence was available. When the scientific literature was incomplete or inconsistent in a particular area, recommendations reflect the consensus of the participants at the symposium (level III evidence). Physicians were recruited from across Canada for their expertise in rheumatology, gastroenterology, epidemiology, gerontology, family practice, and clinical and basic scientific research. BENEFITS, HARMS AND COSTS. Although a reduction in complications due to inappropriate NSAID use should reduce costs of additional investigations, admissions to hospital and time lost from work, definitive cost analysis studies are not yet available. RECOMMENDATIONS. Currently, no NSAID is available that lacks potential for serious toxicity; therefore, long-term use of NSAIDs should be avoided whenever possible, particularly in high-risk patients (e.g., those who are elderly, suffer from hypertension, congestive heart failure, renal or hepatic impairment or volume depletion, take certain concomitant medications or have a history of peptic ulcer disease) (level I evidence). If NSAIDs are to be used in patients with gastric or nephrotoxic risk factors, the lowest effective dose of NSAID should be used (level III evidence); NSAIDs that are weak COX-1 inhibitors may be preferred (level II evidence). In addition, concomitant administration of misoprostol is recommended in patients at increased risk for upper gastrointestinal complications (level I evidence). However, the clinical judgement of the practising clinician must always be part of any therapeutic decision. VALIDATION. These recommendations are based on the consensus of Canadian experts in rheumatology, gastroenterology and epidemiology, and have been subjected to external peer review.     

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.     

腹腔镜仿真子宫模型在妇科住院医师培训中的应用

目的 对比多角度缝合腹腔镜仿真子宫模型和传统外科手术模型的训练效果,探索出更适用于妇科住院医师培训的腔镜模型。方法 选择2021年2月至2023年2月在浙江大学医学院附属邵逸夫医院培训的住院医师48名,分批训练,每批随机平均分为两组,观察组运用传统外科手术模型和普通手术视频进行训练,试验组运用本研究组成员自主研发、可多角度缝合的腹腔镜仿真子宫模型和配套手术视频进行训练。最后对比两组住院医师考核成绩以及对试验组进行问卷调查。采用SPSS 20.0统计软件对结果进行t检验或卡方检验。结果 两组住院医师在年龄、性别分布、学历、临床经验方面差异无统计学意义。试验组[（82.63±3.93）分]和观察组[（85.00±6.15）分]理论成绩差异无统计学意义（P>0.05）。在技能考核上,两组前壁考核差异无统计学意义[（83.08±4.47）分vs.（82.79±3.58）分,P=0.804]。但在侧壁和后壁考核时,试验组熟练度、精确度和双手协调程度均优于观察组,总分差异有统计学意义[（64.13±3.34）分vs.（46.75±3.50）分,（62.25±4.41）分vs.（45.00±2.89）分,P<0.001]。在调查问卷中,试验组对腹腔镜仿真子宫模型的满意度高,认为模型仿真度高,可从中受益。结论 多角度缝合的腹腔镜仿真子宫模型相较于传统外科模型,能高质量地提高住院医师操作水平,为今后妇科住培腹腔镜模型训练提供了新思路。     

Do non-steroidal anti-inflammatory drugs or smoking predispose to Helicobacter pylori infection?

Susceptibility to Helicobacter pylori infection is a poorly understood phenomenon. This study was undertaken to establish whether either smoking or chronic non-steroidal anti-inflammatory drug (NSAID) consumption might in some way predispose to H. pylori infection and hence lead to peptic ulceration. Serological evidence of H. pylori infection was assessed in 100 consecutive subjects receiving NSAIDs without any evidence of gastrointestinal upset and 100 matched controls. All subjects had a full assessment of their smoking habits. Sixty-three per cent of patients taking NSAIDs compared to 51% of controls had evidence of H. pylori infection (NS). Smoking habit also had no effect on H. pylori colonization. The ulcerogenic potential of NSAIDs and smoking does not appear to be mediated via a prediposition to H. pylori infection.     

Prospective study of acute gastrointestinal bleeding attributable to anti-inflammatory drug ingestion in the Yorkshire region of the United Kingdom

Objective: To assess the general use of all non-steroidal anti-inflammatory drugs (NSAID) and their relation to upper gastrointestinal bleeding in view of National Institute for Clinical Excellence guidelines published in July 2001 in the UK. Methods: Cross sectional study on all patients who were referred for endoscopy for suspected upper gastrointestinal bleeding in six hospitals in Yorkshire region of the UK. Results: One hundred and sixty three patients presented for endoscopy for suspected upper gastrointestinal bleeding, 43 patients were taking at least one ulcerogenic drug, and 120 were not. The mean age difference between these two groups was eight years (p<0.01). The absolute difference between the proportion of patients with peptic ulcer disease/erosion (PUD) in NSAID with/without aspirin group and no ulcerogenic drug group was 31% (p = 0.02). The difference between the proportion of PUD in cyclo-oxygenase 2 with/without aspirin group and no ulcerogenic drug group was 30% (p = 0.1). The overall 30 days mortality rate was 14.1%. Conclusions: Elderly patients are being inappropriately prescribed conventional NSAIDs. NSAIDs with or without aspirin use are still associated with a significant risk of upper gastrointestinal bleeding in the era of cyclo-oxygenase 2 selective agents. Substitution with cyclo-oxygenase 2 selective NSAIDs is not without risk of upper gastrointestinal bleeding.     

Computerized Clinical Decision Support During Medication Ordering for Long-term Care Residents with Renal Insufficiency

Objective

To determine whether a computerized clinical decision support system providing patient-specific recommendations in real-time improves the quality of prescribing for long-term care residents with renal insufficiency.

Design

Randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units.

Measurement

The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: (1) recommended medication doses; (2) recommended administration frequencies; (3) recommendations to avoid the drug; (4) warnings of missing information.

Results

The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1,000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1) for the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often in the intervention units—relative risk 1.2 (1.0, 1.4).

Conclusions

Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions.Trial Registration: http://clinicaltrials.gov Identifier: NCT00599209