The Art of Building Decision Trees

Decision support systems that help physicians are becoming a very important part of medical decision making. They are based on different models and the best of them are providing an explanation together with an accurate, reliable, and quick response. One of the most viable among models are decision trees, already successfully used for many medical decision-making purposes. Although effective and reliable, the traditional decision tree construction approach still contains several deficiencies. Therefore we decided to develop and compare several decision support models using four different approaches. We took statistical analysis, a MtDeciT, in our laboratory developed tool for building decision trees with a classical method, the well-known C5.0 tool and a self-adapting evolutionary decision support model that uses evolutionary principles for the induction of decision trees. Several solutions were evolved for the classification of metabolic and respiratory acidosis (MRA). A comparison between developed models and obtained results has shown that our approach can be considered as a good choice for different kinds of real-world medical decision making.Art (from Latin ars meaning skill) is the skill in doing or performing that is attained by study, practice, or observation     

A case study of community-based distribution and use of Misoprostol and Chlorhexidine in Sokoto State,Nigeria

The United States Agency for International Development/Targeted States High Impact Project supported Sokoto State, Nigeria government in the development of a community-based intervention aimed at preventing post-partum haemorrhage (PPH) and cord infection among women and children, respectively. This paper describes the innovative intervention within the Nigeria health delivery system. It then explains the case study approach to assessing this intervention and summarises findings. Ultimately, the intervention was received well in communities and both drugs were added to the procurement list of all health facilities providing maternity services in the State. Key factors leading to such success include early advocacy efforts at the state-level, broad stakeholder engagement in designing the distribution system, early community engagement about the value of the drugs and concerted efforts to monitor and ensure availability of the drugs. Implementation challenges occurred in some areas, including shortage of community-based health volunteers (CBHVs) and drug keepers, and socio-cultural barriers. To maximise and sustain the effectiveness of such interventions, state government needs to ensure constant drug supply and adequate human resources at the community level, enhance counselling and mobilisation efforts, establish effective quality improvement strategies and implement a strong M&E system.     

Vascular calcification and atherosclerosis in hemodialysis patients: what can we learn from the routine clinical practice?

BACKGROUND: Hemodialysis (HD) patients are at increased risk for arterial intimal (AIC) and medial calcification (AMC). METHODS: In a cross-sectional study on 153 HD patients we evaluated the presence of AIC and AMC using plain radiography of the pelvis and the presence of atherosclerotic lesions using high-resolution B-mode ultrasonography of the common carotid arteries (CCA). RESULTS: The radiography of the pelvis confirmed the frequent presence of AIC (35.3%) and AMC (35.9%) in our HD patients. Arterial calcification was absent (non calcified-NC) in a minority of patients (28.8%). Patients with AIC had significantly higher prevalence of atherosclerotic plaques on CCA (78.6%) compared with both other groups and a higher number of documented atherosclerotic complications, such as cardiovascular (85.2%), cerebrovascular (33.3%) and peripheral arterial disease (38.9%) in comparison with the NC patients. According to the 1-year calculated data from patient records, there were no significant differences in the specific HD risks, such as the dose of prescribed calcium carbonate and vitamin D3, serum levels of calcium, phosphate, calcium-phosphate product and intact parathyroid hormone. All four bone metabolism markers within the range proposed by K/DOQI guidelines were achieved in 9.3%, 14.5% and 20.4% in the AIC, AMC and NC group, respectively. CONCLUSIONS: Patients with AIC and AMC are frequently found in the HD population. Screening for arterial calcifications in chronic kidney disease patients is suggested even in the early pre-dialysis period. The highest proportion of patients within the guidelines proposed range for bone and mineral metabolism markers was observed in the NC group. A longer period of data analysis is required in order to evaluate the possible role of some traditional and HD-specific risk factors for the development of arterial calcifications. The achievement of the K/DOQI guidelines is an important issue in the prevention of those conditions.     

GPs facing reluctant and demanding patients: analysing ethical justifications

BACKGROUND: Several studies have explored the physicians' preferred actions when facing a reluctant or a demanding patient, but only a few studies have explored the physicians' justifying reasons. OBJECTIVE: The aim of this study was to assess how GPs would act and how they would justify their choice. METHOD: A postal questionnaire with questions about preferred actions and justifying reasons was sent to a random sample of GPs in Slovenia (n = 160) and Sweden (n = 200) using four vignettes: (i). a healthy patient reluctant to quit smoking; (ii). a healthy patient demanding an X-ray; (iii). a pulmonary cancer patient reluctant to quit smoking; and (iv). a pulmonary cancer patient demanding immunotherapy. RESULTS: The majority of GPs would bring up the question about smoking with the patients reluctant to quit. They justified their choice by referring to promotion of medical benefit and to protection from harm. Swedish GPs were less inclined to bring up smoking than were their Slovenian colleagues. Those who would not bring up the question referred to respect for self-determination and an enhanced relationship as their justifying reasons. With reference to the demanding patients, a minority of GPs would grant the healthy patient's request for an X-ray that was not medically motivated. The answers were similar with respect to the seriously ill patient requesting non-medically motivated immunotherapy. Slovenian GPs were much more inclined to grant the request than were their Swedish colleagues. Enhancing the relationship and respect for self-determination were the most important reasons for granting the demands. When the demands were denied, the GPs mostly referred to promotion of fair distribution of resources. CONCLUSION: Many of the GPs considered their patients' right to self-determination less important than other values, e.g. the obligation to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient-physician relationship.