Clinical Decision Aid Research Articles

Hospital physicians\u2019 experiences with procalcitonin \u2013 implications for antimicrobial stewardship; a qualitative study

BackgroundProcalcitonin is an inflammatory biomarker that is sensitive for bacterial infections and a promising clinical decision aid in antimicrobial stewardship programs. However, there are few studies of physicians’ experiences concerning the use of PCT. The objective of this study was to investigate whether hospital physicians’ experience with procalcitonin after 18 months of use can inform the PCT implementation in antimicrobial stewardship programs.Materials/methodsWe deployed a qualitative approach using semi-structured interviews with 14 hospital physicians who had experience with procalcitonin in clinical practice. Interviews were audio-taped, transcribed verbatim and analysed using thematic analysis.ResultsPhysicians reported a knowledge gap, which made them uncertain about the appropriate procalcitonin use, interpretation, and trustworthiness. Simultaneously, the physicians experienced procalcitonin as a useful clinical decision aid but emphasised that their clinical evaluation of the patient was the most important factor when deciding on antibiotic treatment.ConclusionsProcalcitonin was regarded a helpful clinical tool, but the physicians called for more knowledge about its appropriate uses. Active implementation of unambiguous procalcitonin algorithms and physician education may enhance the utility of the test as an antimicrobial stewardship adjunct.

S42. QUALITATIVE ANALYSIS OF CLINICIANS’ PERSPECTIVES ON THE USE OF A COMPUTERIZED DECISION AID IN THE TREATMENT OF PSYCHOTIC DISORDERS

BackgroundPeople with a psychotic illness have varying care needs in different areas of their life, often over prolonged periods. Symptomatic, medical or psychosocial problems can go undetected and therefore remain untreated. Routine outcome monitoring (ROM) is way to systematically monitor these problems. In addition, multidisciplinary guidelines and standards of care provide suitable evidence-based treatments for most care needs. However, the integration of ROM results and the implementation of guidelines in daily clinical care can still be improved. Clinical decision aids (CDAs) can be used as tools to ingrate ROM results and to implement guidelines into daily clinical practice within psychosis care. Despite the effectiveness of CDAs in different medical disciplines, their use in psychiatric care is rare. Our goal is to successfully implement a clinical decision aid in psychosis care, which can promote the use of evidence-based treatments, based on care need identified by ROM.MethodsWe developed TReatment E-AssisT (TREAT), a computerized clinical decision aid that combines ROM outcomes with evidence-based guidelines in order to generate personalised treatment recommendations. A pilot study was conducted to test the feasibility for implementation in daily clinical practice. Currently, a multicenter trial is conducted to investigate the effects of TREAT on day-to-day patient care. As part of this trial, we have conducted a qualitative analysis of clinicians’ experiences of working with the TREAT application. We interviewed eight psychiatrist and five nurse practitioners who had worked with the application multiple times with different patients during their consultations. Our goal was to gain insight in the way clinicians used TREAT, to uncover implementation barriers and facilitators and to find ways to improve the application for future use. We analysed the data by using a thematic analysis.ResultsThe five themes we identified from the data were; the visual structuring of ROM results, guideline based treatment recommendations, facilitating and obstructing factors, patient effects and shared decision-making. We also identified a clear distinction in the general appraisal of TREAT. Eight clinicians experienced the application as overall benefiting their clinical encounters, while five experienced no additional benefits or sometimes even a negative impact on their daily clinical practice. Clinicians with a more favourable opinion towards TREAT experienced the visual structuring of ROM results and the guideline based recommendations as more positive as opposed to the clinicians with a less favourable opinion. This in turn influenced their clinical reasoning and in some cases their clinical decisions. Different facilitating and obstructing factors were identified, for example; treatment offer within teams, time management and supporting staff. The application did not work equally well for all patient. However, all clinicians agreed that TREAT positively affected shared decision-making during consolations.DiscussionWith TREAT, we have developed an innovative digital tool in psychosis care. A majority of clinicians found the application beneficial for their daily clinical practice. However not all clinicians experienced additional benefits and not all patients seemed fit for TREAT. We identified different barriers and facilitators for implementation and received multiple point of improvement for the future development of the application.

MP05: Validation of the Canadian clinical practice guideline clinical decision aid for acute aortic syndrome

Introduction: Acute aortic syndrome (AAS) is a rare clinical syndrome with a high mortality encompassing acute aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. Up to 38% of cases are misdiagnosed on first presentation. There is a large variation in use of computed tomography to rule out AAS. The Canadian clinical practice guideline for the diagnosis of AAS was developed in order to reduce the frequency of misdiagnoses. As part of the guideline, a clinical decision aid was developed to facilitate clinician decision-making based on practice recommendations. Our objective was to validate the sensitivity of this clinical decision aid. Methods: Our validation cohort was recruited from a retrospective review of all cases of AAS diagnosed at three tertiary care emergency departments and one cardiac referral center from 2002-2019. Inclusion criteria: >18 years old, non-traumatic, symptoms <14 days and AAS confirmed on computed tomography, transesophageal echocardiography, intraoperatively or postmortem. The clinical decision aid assigns an overall score of 0-7 based on high risk pain features, risk factors, physical examination and clinical suspicion. Sensitivity with 95% confidence intervals are reported. Based on a national survey, a miss rate of <1% was predefined for the validation threshold. Results: Data was collected from 2002-2019 yielding 222 cases of AAS (mean age of 65 (SD 14.1) and 66.7% male). Kappa for data abstraction was 0.9. Of the 222 cases of AAS (type A = 125, type B = 95, IMH = 2), 35 (15.7%) were missed on initial assessment. Patients were risk stratified into low (score = 0, 2 (0.9%)) moderate (score = 1, 42 (18.9%)) and high risk (score ≥2,178 (80.2%)) groups. A score ≥1 had a sensitivity of 99.1% (95% CI 96.8-99.9%) in the detection of AAS. The clinical decision aid missed 0.9% (95% CI 0.3-3%) of cases. Conclusion: The Canadian clinical practice guideline's AAS clinical decision aid is a highly sensitive tool that uses readily available clinical information. Although the miss rate was <1%, the 95% confidence intervals crossed the predefined threshold. Further validation is needed in a larger population to ensure the miss rate is below an acceptable level.

P114: Barriers and facilitators affecting implementation of a decision aid for the diagnosis of acute aortic syndrome: a qualitative study

Introduction: Acute aortic syndrome (AAS) is an uncommon, life-threatening emergency that is frequently misdiagnosed. The Canadian clinical practice guidelines for the diagnosis of AAS were developed in order to reduce the frequency of misdiagnoses and number of diagnostic tests. As part of the guidelines, a clinical decision aid was developed in order to facilitate clinician decision-making based on practice recommendations. The objective of this study was to identify barriers and facilitators among physicians to implementation of the decision aid. Methods: We conducted semi-structured interviews with emergency room physicians working at 5 sites distributed between urban academic and rural settings. We used purposive sampling, contacting ED physicians until data saturation was reached. Interview questions were designed to understand potential barriers and facilitators affecting the probability of decision aid uptake and accurate application of the tool. Two independent raters coded interview transcripts using an integrative approach to theme identification, combining an inductive approach to identification of themes within an organizing framework (Theoretical Domains Framework), discrepancies in coding were resolved through discussion until consensus was reached. Results: A majority of interviewees anticipated that the decision aid would support clinical decision making and risk stratification while reducing resource use and missed diagnoses. Facilitators identified included validation and publication of the guidelines as well as adoption by peers. Barriers to implementation and application of the tool included the fact that the use of D-dimer and knowledge of the rationale for its use in the investigation of AAS were not widespread. Furthermore, scoring components were, at times, out of alignment with clinician practices and understanding of risk factors. The complexity of the decision aid was also identified as a potential barrier to accurate use. Conclusion: Physicians were amenable to using the AAS decision aid to support clinical decision-making and to reduce resource use, particularly within rural contexts. Key barriers identified included the complexity of scoring and inclusion criteria, and the variable acceptance of D-dimer among clinicians. These barriers should be addressed prior to implementation of the decision aid during validation studies of the clinical practice guidelines.

LO38: Reducing inappropriate urine culture testing in the emergency department

Background: Urinary tract infections (UTI) are a common emergency department (ED) presentation. Urine cultures (UC) are frequently ordered to confirm the diagnosis, however, it can be challenging to differentiate between a true infection and asymptomatic bacteriuria (ASB) which does not generally benefit from antibiotics. This over-treatment of ASB leads to serious adverse side effects, growing antimicrobial resistance and increased healthcare costs. By reducing inappropriate ED urine culture testing, we can concomitantly avoid the false positives that contribute to this large-scale problem. Aim Statement: We aimed to reduce ED urine culture testing at Credit Valley Hospital, a large community hospital based in Mississauga, Ontario by 30%, from a baseline average of 97 cultures per 1000 ED visits in 2017, to 68 cultures per 1000 ED visits by year end 2019. Measures & Design: Multiple PDSA cycles were ran with our multi-disciplinary ED team. Our interventions to encourage rational urine culture testing are three-fold, including (1) medical directive optimization (removal of routine sending of UC), (2) individualized physician feedback and (3) physician education with introduction of a clinical decision aid. Our outcome measure is rate of UC per 1000 ED patient visits with a balance measure of rate of 30-day ED return visit of hospital admission for patients with a UTI. Evaluation/Results: Despite a parallel surge in ED volumes, we observed a significant decrease in urine culture testing, from an annual average of 97 cultures per 1000 ED visits to 60 cultures per 1000 ED visits in 2019 year-to-date. There was no increase in the rate of ED 30-day return visit or admission for UTI or a diagnostic equivalent. Discussion/Impact: Our multipronged approach effectively decreased the rate of UC testing during the study period. ED physicians provide higher quality care with judicious use of resources to guide diagnosis and management. Active ongoing interventions include our transition to a 2-step UC order protocol (uncoupling urinalysis with culture) using BD vacutainer urine collection products, which will allow for 48 hour storage of uncompromised urine. Further work will leverage our knowledge and experience with optimizing urine culture testing to other culture specimens.

Nonalcoholic steatohepatitis Fitness Intervention in Thrombosis (NASHFit): Study protocol for a randomized controlled trial of a supervised aerobic exercise program to reduce elevated clotting risk in patients with NASH

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of chronic liver disease worldwide affecting upwards of one third the global population. For reasons not fully understood, individuals with NAFLD and its more severe variant, nonalcoholic steatohepatitis (NASH), are at increased risk for venous thromboembolism which significantly increases morbidity and mortality. Lifestyle changes centering around exercise training are the mainstay of treatment for NAFLD/NASH. While exercise training can lessen venous thromboembolic risk in healthy persons and those with cardiovascular disease, whether or not this benefit is seen in patients with NAFLD/NASH remains unknown. In order to better understand how exercise training impacts thrombosis risk in NAFLD, we present the design of a thirty-two week randomized controlled clinical trial of 42 sedentary subjects age 18–69 with biopsy proven NASH. The main aim is to determine the impact of an aerobic exercise training program on the abnormal hemostatic system unique to NAFLD/NASH. The main outcome is change in plasminogen activator inhibitor one level, an established marker for venous thromboembolism. Secondary outcomes include body composition, cardiorespiratory fitness, control of comorbid metabolic conditions (e.g., obesity, hypertension, hyperlipidemia, diabetes), dietary composition, health related quality of life, liver enzymes and histology, NAFLD/NASH disease activity (e.g., biomarkers, clinical decision aids), microbiome, other markers of hemostasis, and PNPLA3 gene expression. The study represents the first clinical trial of an exercise training program to reduce elevated clotting risk in subjects with NAFLD/NASH.

National survey of emergency physicians on the risk stratification and acceptable miss rate of acute aortic syndrome.

One in four cases of acute aortic syndrome are missed. This national survey examined Canadian Emergency physicians' opinion on risk stratification, the need for a clinical decision aid to risk stratify patients, and the required sensitivity of such a tool. We surveyed 1,556 members of the Canadian Association of Emergency Physicians. We used a modified Dillman technique with a prenotification email and up to three survey attempts using electronic mail. Physicians were asked 21 questions about demographics, importance of certain high-risk features, investigation options, threshold for investigation, and if a clinical decision tool is required. We had a response rate of 32%. Respondents were 66% male, and 49% practicing >10 years, with 59% in an academic teaching hospital. A total of 93% reported a need for a clinical decision aid to risk stratify for acute aortic syndrome. A total of 99.6% of physicians were pragmatic accepting a non-zero miss-rate, two-thirds accepting <1%, and the remaining accepting a higher miss-rate. Our national survey determined that emergency physicians would use a highly sensitive clinical decision aid to determine which patients are at low, medium, or high-risk for acute aortic syndrome. The majority of clinicians have a low threshold (<1%) for investigating for acute aortic syndrome, but accept that a zero miss-rate is not feasible.

Establishing guidelines to harmonize tumor mutational burden (TMB): in silico assessment of variation in TMB quantification across diagnostic platforms: phase I of the Friends of Cancer Research TMB Harmonization Project

BackgroundTumor mutational burden (TMB), defined as the number of somatic mutations per megabase of interrogated genomic sequence, demonstrates predictive biomarker potential for the identification of patients with cancer most likely...

Sphere-Forming Culture for Expanding Genetically Distinct Patient-Derived Glioma Stem Cells by Cellular Growth Rate Screening.

Diffusely infiltrating gliomas (DIGs) are difficult to completely resect and are associated with a high rate of tumor relapse and progression from low- to high-grade glioma. In particular, optimized short-term culture-enriching patient-derived glioma stem cells (GSCs) are essential for customizing the therapeutic strategy based on clinically feasible in vitro drug screening for a wide range of DIGs, owing to the high inter-tumoral heterogeneity. Herein, we constructed a novel high-throughput culture condition screening platform called ‘GFSCAN’, which evaluated the cellular growth rates of GSCs for each DIG sample in 132 serum-free combinations, using 13 previously reported growth factors closely associated with glioma aggressiveness. In total, 72 patient-derived GSCs with available genomic profiles were tested in GFSCAN to explore the association between cellular growth rates in specific growth factor combinations and genomic/molecular backgrounds, including isocitrate dehydrogenase 1 (IDH1) mutation, chromosome arm 1p and 19q co-deletion, ATRX chromatin remodeler alteration, and transcriptional subtype. GSCs were clustered according to the dependency on epidermal growth factor and basic fibroblast growth factor (E&F), and isocitrate dehydrogenase 1 (IDH1) wild-type GSCs showed higher E&F dependencies than IDH1 mutant GSCs. More importantly, we elucidated optimal combinations for IDH1 mutant glioblastoma and lower grade glioma GSCs with low dependencies on E&F, which could be an aid in clinical decision-making for these DIGs. Thus, we demonstrated the utility of GFSCAN in personalizing in vitro cultivation to nominate personalized therapeutic options, in a clinically relevant time frame, for individual DIG patients, where standard clinical options have been exhausted.

A novel clinical decision aid to support personalized treatment selection for patients with CT1 renal cortical masses: Results from a multi-institutional competing risks analysis including performance status and comorbidity.

610 Background: Personalized treatment for clinical T1 renal cortical masses (RCMs) should account for competing risks related to tumor and patient characteristics. Using a contemporary multi-institutional cohort, we developed treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-day complication rates for patients managed with surgery, thermal ablation (TA), and active surveillance (AS). Methods: Preoperative clinical and radiological features were collected for eligible patients aged 18-91 years treated at four academic centers from 2000-2016. Prediction models used competing risks regressions for CSM and OCM and logistic regressions for 90-day Clavien &gt;3 complications, adjusting for tumor size as well as patient age, sex, ECOG performance status (PS), and Charlson comorbidity index (CCI). Predictions accounted for missing data using multiple imputation. Results: After excluding 25 patients with no follow-up, the cohort included 4995 patients treated with radical nephrectomy (RN, n=1270), partial nephrectomy (PN, n=2842), thermal ablation (n=479), or active surveillance (n=404). Median follow-up was 5.1 years (IQR 2.5-8.5). Predictions from the fitted model are shown in an online calculator ( https://rgulati.shinyapps.io/rcc-risk-calculator ). To illustrate the use of this calculator for a specific patient, a 70-year-old female with a 5.5 cm RCM, PS of 2, and CCI of 3 has a predicted 5-year CSM of 4-7% across treatments, 5-year OCM of 34-49%, and 90-day risk of Clavien ≥3 complications of 4%, 10%, and 6% for RN, PN, and TA respectively. Conclusions: Personalized treatment selection for cT1 RCM is challenging. We present a competing risk calculator that incorporates pretreatment features to quantify competing causes of mortality and treatment-associated complications. Pending validation, this tool may be used in clinical practice to provide patients with estimated individualized treatment-specific probabilities of competing causes of death and complication risks to facilitate shared decision-making.

Unravelling the benefits and barriers to utilising whole-genome sequencing in the investigation of outbreaks

Background This prospective study was established to develop and evaluate methods to harness pathogen sequencing in the clinical microbiology environment. We describe new insights into the clinical benefits of using whole-genome sequencing (WGS) for outbreak investigation with solutions for the practical barriers to implementation in clinical settings. Methods Surveillance software (ICNet) and statistical process control charts (SPCs) detected potential outbreaks of meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), Enterobacteriaceae producing extended spectrum β-lactamases (ESBLs), Listeriaspp. and optrAgene positive enterococci. Isolates were sent to reference laboratories for conventional typing and the Infection Group, School of Medicine, University of St Andrews for WGS (Illumina Inc, San Diego, CA, USA) and bioinformatic data analysis. Results Over 400 isolates have been sequenced to date. WGS replaced multiple typing techniques in a Pseudomonas aeruginosa ICU outbreak. It confirmed two patient’s Listeria spp. isolates were indistinguishable prompting hospital kitchen inspections, identified a patient to be carrying two strains of VRE and confirmed that vancomycin-sensitive Enterococcus faecium isolates related to a VRE cluster. We observed five main barriers to implementing WGS (infrastructure, performance/quality assessment of data, isolate selection, clinical result interpretation and database management). Conclusion WGS is beneficial in outbreaks of uncommon organisms and when conventional typing cannot show whether isolates are linked or not. Identifying barriers assisted us in developing a clinical decision aid that can be used by clinicians when applying WGS to outbreak investigations.

Portal Venous Pulsatility Index: A Novel Biomarker for Diagnosis of High-Risk Nonalcoholic Fatty Liver Disease.

OBJECTIVE. The purpose of this study was to assess the accuracy of portal vein pulsatility for noninvasive diagnosis of high-risk nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS. This retrospective study included patients with biopsy-proven diagnosis of NAFLD who underwent duplex Doppler ultrasound assessment of the main portal vein within 1 year of liver biopsy (January 2014 to February 2018). Doppler ultrasound images were reviewed. The spectral waveform was used to measure the maximum (Vmax) and minimum (Vmin) velocity of blood in the portal veins. Venous pulsatility index (VPI) defined as (Vmax - Vmin) / Vmax was calculated. ROC curve analysis was used to calculate AUC as a measure of accuracy to determine the value of this index for diagnosis of high-risk NAFLD and compared with that of the following four clinical decision aids: NAFLD fibrosis score (FS), fibrosis-4 index (FIB-4), BARD score (body mass index, aspartate aminotransferase [AST]-to-alanine aminotransferase ratio, diabetes mellitus), and AST-to-platelet ratio index (APRI). The value of adding VPI to these indexes was also investigated. RESULTS. Of 123 study subjects, 33 (26.8%) had high-risk NAFLD and were found to have a lower VPI than the other 90 subjects (0.19 vs 0.32; p < 0.001). VPI, NAFLD FS, FIB-4, and APRI had statistically significant diagnostic values for high-risk NAFLD. VPI had the highest optimism-corrected AUC (VPI, 0.84 [95% CI, 0.77-0.91]; NAFLD FS, 0.74 [95% CI, 0.63-0.83]; FIB-4, 0.81 [95% CI, 0.72-0.89]; APRI, 0.73 [95% CI, 0.61-0.82]). Addition of VPI to any of the four scoring systems significantly improved the diagnostic value of the score for high-risk NAFLD. CONCLUSION. VPI may be an accurate noninvasive biomarker for diagnosis of high-risk NAFLD.

Three-dimensional computed tomography mapping of posterior malleolar fractures.

Posterior malleolar fractures have been reported to occur in < 40% of ankle fractures. To reveal the recurrent patterns and characteristics of posterior malleolar fractures by creating fracture maps of the posterior malleolar fractures through the use of computed tomography mapping. A consecutive series of posterior malleolar fractures was used to create three-dimensional reconstruction images, which were oriented and superimposed to fit an ankle model template by both aligning specific biolandmarks and reducing reconstructed fracture fragments. Fracture lines were found and traced in order to generate an ankle fracture map. This study involved 112 patients with a mean age of 49, comprising 32 pronation-external rotation grade IV fractures and 80 supination-external rotation grade IV fractures according to the Lauge-Hansen classification system. Three-dimensional maps showed that the posterior ankle fracture fragments in the supination-external rotation grade IV group were relatively smaller than those in the pronation-external rotation grade IV group after posterior malleolus fracture. In addition, the distribution analyses on posterior malleolus fracture lines indicated that the supination-external rotation grade IV group tended to have higher linear density but more concentrated and orderly distribution fractures compared to the pronation-external rotation grade IV group. Fracture maps revealed the fracture characteristics and recurrent patterns of posterior malleolar fractures, which might help to improve the understanding of ankle fracture as well as increase opportunities for follow-up research and aid clinical decision-making.

A Systematised State-of-the-Art Review of Machine Learning Models to Aid Clinical Decision-Making in Epilepsy

A Systematised State-of-the-Art Review of Machine Learning Models to Aid Clinical Decision-Making in Epilepsy

Framework for improving outcome prediction for acute to chronic low back pain transitions.

Clinical practice guidelines and the Federal Pain Research Strategy (United States) have recently highlighted research priorities to lessen the public health impact of low back pain (LBP). It may be necessary to improve existing predictive approaches to meet these research priorities for the transition from acute to chronic LBP. In this article, we first present a mapping review of previous studies investigating this transition and, from the characterization of the mapping review, present a predictive framework that accounts for limitations in the identified studies. Potential advantages of implementing this predictive framework are further considered. These advantages include (1) leveraging routinely collected health care data to improve prediction of the development of chronic LBP and (2) facilitating use of advanced analytical approaches that may improve prediction accuracy. Furthermore, successful implementation of this predictive framework in the electronic health record would allow for widespread testing of accuracy resulting in validated clinical decision aids for predicting chronic LBP development.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process

ObjectiveThe purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities. MethodsA consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range. ResultsThirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool. ConclusionThis study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

The usefulness of a novel patient management decision aid to improve clinical decision-making skills in final year chiropractic students

BackgroundThe process of developing patient management plans requires a series of clinical decision-making skills that can take years in practice to develop. For the inexperienced practitioner, providing a logical, systematic patient management framework may assist in clinical scenarios and accelerate their decision-making skill development. The purpose of this study was to assess whether a novel clinical management decision aid would improve the management decision-making of chiropractic students.MethodsA prospective before and after study tracked chiropractic master degree students in their final year of study across a 10-week period from February–May, 2017. Case-based assessments were performed at baseline, after initial exposure to the decision aid, and after repeated exposure over the course of the semester. Outcome measures included the results from the 3 assessments, scored out of 20 by two markers using a standardised marking rubric, then averaged and converted to percentages; and 2 feedback questionnaires, given after initial exposure and at 10 weeks.ResultsA total of 75 students (44 males; 31 females) participated in the study. The mean score at baseline was 8.34/20 (41.7%) (95% CI: 7.98, 8.70; SD: 1.56) and after initial exposure was 9.52/20 (47.6%) (95% CI: 9.06, 9.98; SD: 2.02). The mean score after repeated exposure was 15.04/20 (75.2%) (95% CI: 14.46, 15.62; SD: 2.54). From baseline to initial exposure, there was a statistically significant absolute increase in mean score of 1.18/20 (5.9%) (95% CI: 0.6, 1.76; p < 0.0001), or a 2.82/20 (14.1%) relative improvement. From baseline to repeated exposure, there was a statistically significant absolute increase in mean score of 6.7/20 (33.5%) (95% CI: 6.02, 7.38; p < 0.0001), or a 16.06/20 (80.3%) relative improvement. The questionnaire results were also favourable. 56/75 (75%) participants agreed that the decision aid was easy to use and 46/75 (61%) of participants agreed that the decision aid improved their ability to integrate various management techniques.ConclusionImplementing a clinical management decision aid into the teaching curriculum helped to facilitate the ability of chiropractic students to develop patient management plans.

A Feasibility Study of an AI-Powered Clinical Decision Aid for Personalized Depression Treatment Selection

A Feasibility Study of an AI-Powered Clinical Decision Aid for Personalized Depression Treatment Selection

Surgical Management of Breast Cancer in Turkey: a 30-Year Single-Center Retrospective Study of 2531 Patients

Mastectomy and lumpectomy are well-established surgical methods for the surgical treatment of breast cancer. The comparison of these methods within the 30-year period in terms of clinicopathological characteristics, recurrence, and survival patterns is required in order to provide aid in clinical decision-making. A total of 2531 women who underwent mastectomy or lumpectomy between 1982 and 2012 for primary invasive breast tumors were compared. Starting from 2003, similar variables for patients with primary invasive breast tumors who underwent sentinel node biopsy (SNB) were presented. Mastectomy was performed in 1870 patients and lumpectomy in 661. The median follow-up was 38 months for all patients. The ratio of mastectomy was lower for the patients who underwent SNB. There was no significant difference in breast cancer-related survival or disease-free survival between lumpectomy and mastectomy even after adjusting for the clinicopathological variables. Lumpectomy and mastectomy demonstrate similar survival rates for patients with invasive breast carcinoma. Tumor grade, stage, hormone receptor status, lymphovascular invasion, and distant recurrence have an impact on breast cancer-related survival.

EHealth interventions for people with chronic kidney disease.

Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours. This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD. We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type. Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE. We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I2 = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I2 = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision. eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.