Care Decisions Research Articles

SP1.3 - Surgical Practices in Emergency Umbilical Hernia Repair and Implications for Trial Design

Abstract Aims There is variation in the investigation, management, and surgical technique of acutely symptomatic abdominal wall hernias and optimal strategies remain to be established. This survey aimed to identify key variables influencing decision-making and preferred surgical techniques in emergency umbilical hernia care to help inform trial design and understand potential challenges to trial delivery. Methods A survey was distributed to surgeons through social media, personal contacts, and ASGBI lists. It comprised five sections: (i) performer of repair, (ii) repair preferences, (iii) important outcomes, (iv) antibiotic use, and (v) trial design. Results There were 105 respondents, of which 49 (46.6%) were consultants. The median largest defect surgeons would attempt to repair with sutures alone was 2cm (IQR 2-4cm). In the acute setting, the most common mesh preferences are preperitoneal plane placement (n=61, 58.1%), with synthetic non-absorbable mesh (n=72, 68.6%), in clean (n=41, 39.0%) or clean-contaminated (n=52, 49.5%) wounds. Respondents believed suture repair to be associated with better short-term outcomes, and mesh repair with better long-term outcomes. The trial design felt to most likely influence practice is comparing mesh and suture repair, and also comparing post-operative antibiotics versus no post-operative antibiotics. Respondents indicated that to change their practice, the median difference in surgical site infection rate and recurrence rate would both need to be 5%. Conclusion This survey provides insight into surgical preferences in emergency umbilical hernia management, offering guidance for future trial designs. Such designs should align with existing evidence and incorporate patient and public involvement to ensure a meaningful impact.

End-of-life medical decisions in French overseas departments: results of a retrospective survey

BackgroundFrench laws governing end-of-life medical practices forbid euthanasia and affirm patients’ right to deep and continuous sedation until death. Cultural traditions and disparities in health care provision, as in overseas France, could limit the enforcement of such laws and modify end-of-life medical practices.AimThis research aims to describe end-of-life medical decisions in overseas France and to compare with those described in mainland France.MethodsA retrospective study of a random sample of adult patients who died between March 2020 and February 2021 was conducted in four overseas French departments. Physicians who certified the deaths were asked to describe end-of-life care and medical decisions in a questionnaire.ResultsA total of 1815 deaths were analysed over 8730 questionnaires sent. Withholding treatments was the most frequent decision (41%), treatment for pain or symptoms was intensified for a third of patients, Deep and continuous sedation until death was implemented in 13.3% cases. The use of drugs to deliberately end life was mentioned in 1.3% deaths. At least one decision was made in 61.6% deaths. More decisions that may hasten death were made before predictable deaths. Intensification of pain and symptoms treatment was more frequent in 2022 than in 2010. Deep and continuous sedation was introduced by law in 2016 without prejudice to other decisions.ConclusionPhysicians in overseas France have implemented recent changes in end-of-life laws, including deep and continuous sedation. Comparisons with 2010 mainland France survey show a better implementation of palliative medicine in 2022, with higher proportions of treatment withholding.

Study on the public awareness of stroke risk factors, symptoms, treatment and rehabilitation: A community based cross sectional survey from a tertiary referral centre in South India

Background: The incidence of Non communicable diseases (NCDs) including stroke is increasing in India over the past few years. Thrombolysis therapy has revolutionized management of acute ischemic stroke. In spite of such recent advances in stroke therapy, the public remains uninformed about stroke symptoms and management. Objective: To assess the public awareness of stroke risk factors, symptoms, treatment and rehabilitation measures. Methods: The study was a community-based cross-sectional study, designed as an online survey. The tool used for the survey was a semi-structured online questionnaire. Results: Regarding the risk factors of stroke, of the participants, 41 (14.8%) were aware of valvular heart diseases, 18 (6.5%) of lack of exercise, 238 (85.9%) of dyslipedemia, 236 (85.2%) of hypertension, 222 (80.1%) of smoking, and 154 (55.6%) of diabetes. Regarding symptoms of stroke, of the participants, 209 (75.5%) were aware of loss of balance, 240 (86.6%) of speech abnormalities, 261 (94.2%) of facial weakness, and 234 (84.5%) of weakness. Conclusion: Efforts should be made to educate the public regarding uncommon symptoms of stroke, thrombolysis treatment and rehabilitation measures, so that people make beneficial health care decisions in stroke management.

Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.

Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented. A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure. In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259. A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

Toward Personalized Care and Patient Empowerment and Perspectives on a Personal Health Record in Hemophilia Care: Qualitative Interview Study.

To enable personalized treatment and shared decision-making in chronic care, relevant health information is collected. However, health information is often fragmented across hospital information systems, digital health apps, and questionnaire portals. This also pertains to hemophilia care, in which scattered information hampers integrated care. We intend to co-design a nationwide digital personal health record (PHR) for patients to help manage their health information. For this, user perspectives are crucial. This study aims to assess patients' and health care providers' perspectives regarding the use of a PHR in hemophilia care in the Netherlands, required functionalities, and expectations and concerns. In this semistructured interview study, 19 pediatric and adult persons with hemophilia, parents, and women with other inherited bleeding disorders, as well as 18 health care providers working within and outside of hemophilia treatment centers, participated. Perspectives of patients and providers were explored separately. To explore requirements, participants were asked to prioritize functionalities. Participants expected a PHR would increase the transparency of health information, improve patients' understanding of their illness, and help the coordination of care between health care providers and institutions. Prioritized functionalities included the integration of relevant health information and patient-entered data. Formulated expectations and concerns focused on 4 themes: usability, safety, inclusiveness, and implementation. While patients expressed worries over medicalization (ie, more confrontational reminders of their illness), providers were concerned about an increased workload. People with hemophilia, their parents, and health care providers welcomed the development of a PHR, as they expected it would result in better coordinated care. Formulated expectations and concerns will contribute to the successful development of a PHR for persons with hemophilia, and ultimately, for all persons with a chronic condition.

Impact of the life-sustaining treatment decision act on organ donation in out-of-hospital cardiac arrests in South Korea: a multi-centre retrospective study

BackgroundThe demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act (LSTDA) in February 2018. This legislation may influence emergency medical procedures and the availability of organs from brain-dead donors. This study aimed to assess LSTDA’s impact, introduced in February 2018, on organ donation status in out-of-hospital cardiac arrest (OHCA) patients in a metropolitan city and identified related factors.MethodsWe conducted a retrospective analysis of a regional cardiac arrest registry. This study included patients aged 16 or older with cardiac arrest and a cerebral performance category (CPC) score of 5 from January 2015 to December 2022. The exclusion criteria were CPC scores of 1–4, patients under 16 years, and patients declared dead or transferred from emergency departments. Logistic regression analysis was used to analyse factors affecting organ donation.ResultsOf the 751 patients included in this study, 47 were organ donors, with a median age of 47 years. Before the LSTDA, there were 30 organ donations, which declined to 17 after its implementation. In the organ donation group, the causes of cardiac arrest included medical (34%), hanging (46.8%), and trauma (19.2%). The adjusted odds ratio for organ donation before the LSTDA implementation was 6.12 (95% CI 3.09–12.12), with non-medical aetiology as associated factors.ConclusionThe enactment of the LSTDA in 2018 in South Korea may be linked to reduced organ donations among patients with OHCA, underscoring the need to re-evaluate the medical and legal aspects of organ donation, especially considering end-of-life care decisions.

Building a learning health care community in rural and remote areas: a systematic review

BackgroundA Learning Health Care Community (LHCC) is a framework to enhance health care through mutual accountability between the health care system and the community. LHCC components include infrastructure for health-related data capture, care improvement targets, a supportive policy environment, and community engagement. The LHCC involves health care providers, researchers, decision-makers, and community members who work to identify health care needs and address them with evidence-based solutions. The objective of this study was to summarize the barriers and enablers to building an LHCC in rural areas.MethodsA systematic review was conducted by searching electronic databases. Eligibility criteria was determined by the research team. Published literature on LHCCs in rural areas was systematically collected and organized. Screening was completed independently by two authors. Detailed information about rural health care, activities, and barriers and enablers to building an LHCC in rural areas was extracted. Qualitative analysis was used to identify core themes.ResultsAmong 8169 identified articles, 25 were eligible. LHCCs aimed to increase collaboration and co-learning between community members and health care providers, integrate community feedback in health care services, and to share information. Main barriers included obtaining adequate funding and participant recruitment. Enablers included meaningful engagement of stakeholders and stakeholder collaboration.ConclusionsThe LHCC is built on a foundation of meaningful use of health data and empowers health care practitioners and community members in informed decision-making. By reducing the gap between knowledge generation and its application to practice, the LHCC has the potential to transform health care delivery in rural areas.

Impact of shared decision-making in Taiwanese patients with atrial fibrillation eligible for novel oral anticoagulant therapy

Background/PurposeShared decision-making (SDM) promotes patient awareness about medical conditions and treatments, facilitating patient involvement in care decisions. This two-stage multicenter study evaluated impacts of SDM in Taiwanese adults with atrial fibrillation (AF) eligible for novel oral anticoagulant (NOAC) therapy. MethodsParticipants were NOAC-naïve (part I) or dabigatran-experienced (part II). During Stage I, part I participants (n = 124) completed a semi-structured survey (understanding evaluation sections only) before and after viewing SDM materials on stroke prevention for AF. Surveys collected data on anxiety about AF, confidence in healthcare professionals, usefulness of the SDM materials, and perception of different NOACs. During Stage II, part I participants after being prescribed NOACs, and part II participants completed another survey to compare impacts of SDM. ResultsDuring Stage I, dabigatran was the preferred NOAC after viewing the SDM materials among 90% of part I participants. During Stage II, both part I (n = 87) and part II participants (n = 104) completed another survey. Fewer part I participants were anxious about AF (p < 0.01), and more had confidence in healthcare professionals (p < 0.01) after viewing SDM materials than before. Most part I participants (≥90%) rated the SDM materials as “very helpful”. In Stage II, participants viewing SDM before initiating dabigatran had lower anxiety (part I, 43%; part II, 53%; p < 0.01) and a higher trust (part I, 92%; part II, 84%; p < 0.01). ConclusionIn conclusion, SDM reduced anxiety and improved trust in healthcare professionals among NOAC-naïve participants with AF.

A Tool Integrated into the Electronic Health Record to Guide Proper Decision-Making Regarding Peri-Endoscopic Anticoagulant Management: A Retrospective Cohort Study.

Background-Anticoagulants, such as vitamin-K antagonists (VKA) and direct oral anticoagulants (DOAC), are widely used among patients who undergo endoscopic procedures. To balance between bleeding and thromboembolic risks, careful decisions must be made about whether and for how long anticoagulants have to be stopped peri-endoscopically and if bridging is necessary. We created a tool in the electronic health records system (EHR) HIX (Microsoft) for invasive procedures to aid this decision-making. By selecting the anticoagulant indication or thrombo-embolic risk and the bleeding risk of the procedure, the tool automatically generates advice for periprocedural anticoagulant management. Objectives-This study assesses whether the tool is used properly peri-endoscopically. Secondly, it examines how many bleeding and thromboembolic events have occurred since the implementation of the tool. Methods-This retrospective study included all orders placed for endoscopies for patients using VKA or DOAC between 2018 and 2021. Results-In total, 986 endoscopies were included for analysis. In 89%, the tool was used correctly; the main error was selecting the wrong bleeding risk (7.5%). The cumulative incidence for moderate or severe bleeding events for DOAC and VKA was 2 (0.5%) and 0, respectively. The cumulative incidence of thromboembolic events for DOAC and VKA was 1 (0.2%) for each. Conclusions-This study evaluates the use of an EHR-integrated decision-making tool to aid peri-endoscopic anticoagulant management. By analysing the usage of the tool, we formulated several suggestions to improve the tool. Although this study is not a comparative one, we can conclude that the thromboembolic and major bleeding risks were low.

BIOMECHANICAL VARIABLES OF THE FOOT IN SOUND RETICULATED GIRAFFES (GIRAFFA CAMELOPARDALIS RETICULATA) IN HUMAN CARE.

Lameness is an important veterinary and welfare concern for giraffes in human care. To date, there is limited information on the objective weight-bearing characteristics of the foot in giraffes, making evidence-based decisions for foot care and lameness treatment subjective. Eleven young-adult reticulated giraffes (Giraffa camelopardalis reticulata; median age, 3.5 yr [range, 13 mon-13 yr]), with no clinical lameness or visible hoof overgrowth when viewed from standing, voluntarily walked across a commercially available pressure-sensitive walkway. Footfalls were analyzed for force, pressure, surface area, and impulse from each foot. The weight-bearing claw was also determined based on pressure in both the front and hind limbs. The data obtained suggest that the main weight-bearing claw is the lateral claw in both the forelimbs and the hind limbs the majority of the time, but is inconsistent. The forelimbs also had greater values for all biomechanical variables than the hind limbs. The higher force and pressure suggest that giraffe forelimbs are subjected to greater biomechanical stress than the hind limbs. The relative maximum force from front limbs to hind limbs was 59:41. For these clinically sound giraffes, the center of force was consistently located in the interdigital space approximately equidistant from the toe and heel correlating with the center of mass of the limb. Furthermore, foot strikes occurred in a heel-first pattern. A pressure-sensitive walkway was well tolerated by all animals in the study and may be used in future research to help further elucidate factors that contribute to lameness in giraffes.

Behind the screen: exploring the effects of home working on 999 telephone clinicians during the COVID-19 pandemic.

The COVID-19 pandemic has significantly stretched global healthcare provisions since its commencement in 2019. From the outset, ambulance services in the UK had to adapt and change their working practices to meet distancing requirements, to increase staff numbers and to ease the effects of staff becoming unavailable for work due to self-isolation and illness. One strategy was moving clinicians from emergency operation centres (EOCs) to working from home. Like many international services, UK ambulance services use paramedics and nurses to undertake telephone and video assessments of patients calling the 999 emergency services line in a model known as virtual care or remote clinical decision making. Virtual care is any interaction between a patient and a clinician or clinicians, occurring remotely via information technologies.Increasing evidence is becoming available to suggest that the pandemic caused harm to the well-being of healthcare workers, primarily due to the severe stress of regular exposure to death and human suffering. However, there remains a dearth of literature focusing on the well-being of remote and virtual clinicians, especially those who moved from working in EOCs to working at home during the COVID-19 pandemic. Therefore, this study reports the findings of a qualitative analysis of these effects from the clinician's perspective. The authors hope that the findings from this study will inform the operating, well-being and leadership practices of those delivering such services. A convenience sample of telephone nurses and paramedics from one UK ambulance service where home working had been implemented were contacted. Fifteen clinicians with recent home-working experience responded to the invitation to participate out of a possible 31 (48%). All participants had previously practised remote assessment from within an EOC. Semi-structured interviews took place via video-conferencing software and were recorded, transcribed and thematically analysed. An inductive approach was taken to generating codes, and both researchers separately read the transcripts before re-reading them, assigning initial themes and determining frequency. Five main themes were discovered, with further associated sub-themes. The main themes were: safety; financial implications; working relationships; home-working environment; and anxiety. Few studies explore remote clinicians' health and well-being. This study identified that home-working clinicians felt that there had been no detrimental impact on their health and well-being because of working from home during the initial phase of the COVID-19 pandemic. While some concerns were raised, these were mitigated through the support that clinicians received at home from family members, as well as from colleagues, some of whom had developed new working relationships. Financial implications appeared to have contributed to some concerns for participants initially, but these had been alleviated quickly despite requiring further exploration of the true financial impact of working from home.

O84 BLOOD PRESSURE MEASUREMENT VIA IMPEDANCE CARDIOGRAPHY: AN ARTIFICIAL INTELLIGENCE BASED PROOF-OF-CONCEPT

Objective: Accurate blood pressure (BP) measurement is crucial for the diagnosis, risk assessment, treatment decision-making, and monitoring of cardiovascular diseases. Unfortunately, the gold-standard, cuff-based BP measurement suffer from inaccuracies and discomfort. As a result, continuous, cuff-less, and non-invasive BP assessment methods are merging as promising alternatives. This study is the first to comprehensively assess impedance cardiography (ICG) for Machine Learning enabled BP measurement. Methods: We analysed ICG data from 71 young and healthy adults. Nine different Machine Learning algorithms were evaluated for their BP estimation performance. Accuracy measures comprised mean difference, standard deviation, Limits of Agreement, mean absolute error, and root mean squared error. Additionally, the B-Score was calculated to evaluate the “true”, relative performance of the best-performing model. Results: The Multi-Linear Regression model showed the highest performance (mean difference = -0.01, r = 0.82) for systolic BP. The Support Vector Regressor model achieved the best results (mean difference = 0.15, r = 0.51) for diastolic BP. Both models exhibited positive B-Scores, indicative of their predictive capability. All tested models’ estimations correlated with both systolic and diastolic reference BP (r &gt; 0.72 / r &gt; 0.34, p &lt; 0.001). Conclusion: The study highlights the potential of ICG based Machine Learning algorithms for accurately estimating arterial BP. Such algorithms can provide accurate and continuous BP data. This offers the possibility of enhancing patient care, timely diagnostics, and treatment decision-making. Our approach is especially promising for post-surgical and intensive care environments.

Development and Preliminary Validation of Scales to Measure Enacted, Perceived, and Experienced Hearing Loss Stigma in Health Care Settings.

Qualitative evidence suggests that stigma experienced by people who are d/Deaf and hard of hearing (d/DHH) can reduce willingness to engage with health services. Quantitative evidence remains lacking, however, about how health care providers (HCPs) perceive societal stigma toward people who are d/DHH, how HCPs might enact d/DHH stigma within provider-patient encounters, and what patients who are d/DHH share with providers about those patients' perceptions and experiences of stigma. Such quantitative evidence would allow HCPs to understand if and how stigma influences hearing health decisions made by people who are d/DHH. It could also shape practices to reduce d/DHH stigma within clinical encounters and guide providers in considering stigma as a driving force in their patients' hearing health care decisions. Building that evidence base requires validated quantitative measures. In response, the present study initiated an iterative process toward developing and preliminarily validating HCP self-report measures for different forms of d/DHH stigma. These measures draw upon HCPs' own perspectives, as well as their reports of secondhand information about stigma shared during clinical conversations. We developed and preliminary validated four measures: (1) provider-perceived stigma (HCPs' perceptions of the existence of negative attitudes and stereotypes toward d/DHH individuals in society), (2) provider-enacted stigma (self-reported subtle or indirect acts of stigma HCPs might commit during clinical encounters), (3) secondhand patient-experienced stigma (external acts of stigma reported to HCPs by patients who are d/DHH during clinical encounters), and (4) secondhand patient-perceived stigma (perceptions of negative attitudes and stereotypes reported to HCPs by patients who are d/DHH during clinical encounters). Scale items were extracted from a comprehensive literature review of stigma measures. Question stems and individual items were adapted for HCPs, cognitively tested on 5 HCPs, and pretested with 30 HCPs. The 4 scales were then validated on a sample of primary care providers and hearing care specialists (N = 204) recruited through an online survey. All data were collected in the United States. We conducted an exploratory factor analysis of the four proposed d/DHH stigma HCP stigma scales. Scale items loaded satisfactorily with ordinal alphas ranging between 0.854 and 0.944. The four measures developed and preliminarily validated in this study can provide opportunities for HCPs to develop a more nuanced understanding of stigma experienced and perceived by their patients who are d/DHH and how that stigma manifests across social contexts, including health care settings. Further, the ability to assess forms of d/DHH stigma in clinical encounters, as well as their association with patient disengagement and resistance to advanced hearing care, could lead to innovative stigma-reduction interventions. Such interventions could then be evaluated using the measures from this article and then applied to clinical practice. We envision these measures being further refined, adapted, and tested for a variety of health care contexts, including primary care settings where hearing difficulties may first be identified and in hearing health care settings where audiologic rehabilitation is initiated.

Challenges for pathologists in implementing clinical microbiome diagnostic testing.

Recent research has established that the microbiome plays potential roles in the pathogenesis of numerous chronic diseases, including carcinomas. This discovery has led to significant interest in clinical microbiome testing among physicians, translational investigators, and the lay public. As novel, inexpensive methodologies to interrogate the microbiota become available, research labs and commercial vendors have offered microbial assays. However, these tests still have not infiltrated the clinical laboratory space. Here, we provide an overview of the challenges of implementing microbiome testing in clinical pathology. We discuss challenges associated with preanalytical and analytic sample handling and collection that can influence results, choosing the appropriate testing methodology for the clinical context, establishing reference ranges, interpreting the data generated by testing and its value in making patient care decisions, regulation, and cost considerations of testing. Additionally, we suggest potential solutions for these problems to expedite the establishment of microbiome testing in the clinical laboratory.

Comparing the Ability of Google and ChatGPT to Accurately Respond to Oculoplastics-Related Patient Questions and Generate Customized Oculoplastics Patient Education Materials.

To compare the accuracy and readability of responses to oculoplastics patient questions provided by Google and ChatGPT. Additionally, to assess the ability of ChatGPT to create customized patient education materials. We executed a Google search to identify the 3 most frequently asked patient questions (FAQs) related to 10 oculoplastics conditions. FAQs were entered into both the Google search engine and the ChatGPT tool and responses were recorded. Responses were graded for readability using five validated readability indices and for accuracy by six oculoplastics surgeons. ChatGPT was instructed to create patient education materials at various reading levels for 8 oculoplastics procedures. The accuracy and readability of ChatGPT-generated procedural explanations were assessed. ChatGPT responses to patient FAQs were written at a significantly higher average grade level than Google responses (grade 15.6 vs 10.0, p < 0.001). ChatGPT responses (93% accuracy) were significantly more accurate (p < 0.001) than Google responses (78% accuracy) and were preferred by expert panelists (79%). ChatGPT accurately explained oculoplastics procedures at an above average reading level. When instructed to rewrite patient education materials at a lower reading level, grade level was reduced by approximately 4 (15.7 vs 11.7, respectively, p < 0.001) without sacrificing accuracy. ChatGPT has the potential to provide patients with accurate information regarding their oculoplastics conditions. ChatGPT may also be utilized by oculoplastic surgeons as an accurate tool to provide customizable patient education for patients with varying health literacy. A better understanding of oculoplastics conditions and procedures amongst patients can lead to informed eye care decisions.

Assessing the quality of ChatGPT's responses to questions related to radiofrequency ablation for varicose veins

ObjectiveThis study aimed to evaluate the accuracy and reproducibility of information provided by ChatGPT, in response to frequently asked questions about radiofrequency ablation (RFA) for varicose veins. MethodsThis cross-sectional study was conducted at The Aga Khan University Hospital, Karachi, Pakistan. A set of 18 frequently asked questions regarding RFA for varicose veins were compiled from credible online sources and presented to ChatGPT twice, separately, using the new chat option. Twelve experienced vascular surgeons (with >2 years of experience and ≥20 RFA procedures performed annually) independently evaluated the accuracy of the responses using a 4-point Likert scale and assessed their reproducibility. ResultsMost evaluators were males (n = 10/12 [83.3%]) with an average of 12.3 ± 6.2 years of experience as a vascular surgeon. Six evaluators (50%) were from the UK followed by three from Saudi Arabia (25.0%), two from Pakistan (16.7%), and one from the United States (8.3%). Among the 216 accuracy grades, most of the evaluators graded the responses as comprehensive (n = 87/216 [40.3%]) or accurate but insufficient (n = 70/216 [32.4%]), whereas only 17.1% (n = 37/216) were graded as a mixture of both accurate and inaccurate information and 10.8% (n = 22/216) as entirely inaccurate. Overall, 89.8% of the responses (n = 194/216) were deemed reproducible. Of the total responses, 70.4% (n = 152/216) were classified as good quality and reproducible. The remaining responses were poor quality with 19.4% reproducible (n = 42/216) and 10.2% nonreproducible (n = 22/216) . There was nonsignificant inter-rater disagreement among the vascular surgeons for overall responses (Fleiss' kappa, −0.028; P = .131). ConclusionsChatGPT provided generally accurate and reproducible information on RFA for varicose veins; however, variability in response quality and limited inter-rater reliability highlight the need for further improvements. Although it has the potential to enhance patient education and support health care decision-making, improvements in its training, validation, transparency, and mechanisms to address inaccurate or incomplete information are essential.

A bottom-up framework for nurses' protocol-based care decision-making.

To develop a conceptual framework for nurses' protocol-based care decision-making. Miles & Huberman's bottom-up approach to developing conceptual frameworks was followed, using data collected from a multiple embedded case study examining protocol-based decision-making by nurses in three hospital wards within a university hospital in northern Spain. The qualitative data from the case study, obtained through documentary analysis, observations, and interviews, underwent a secondary analysis consisting of four steps: data reduction, data display, comparison, and drawing conclusions. The framework for protocol-based care decision-making comprises four components: (1) protocol-based care, as a balance between standardisation and individualised care, (2) the process, (3) the context, and (4) the elements of protocol-based care decision-making. These components and their relationship as a context-dependent, linear, variable and multifactorial process, directly influenced by the perception of risk, are described and illustrated. This study provides a rigorous bottom-up framework for nurses' protocol-based care decision-making. The framework could be a valuable resource for managers, clinical nurses, educators, and researchers to guide and evaluate nurses' decision-making, leading to improved care quality and reduced variability in clinical practice. Furthermore, the framework lays a foundation for further research and practical applications. This study addressed the problem of understanding nurses' protocol-based care decision-making and the need for a specific conceptual framework. The main findings of the study contribute to the development of a rigorous bottom-up framework comprising four components of protocol-based care decision-making. The framework has the potential to improve care quality, reduce variability, enhance patient safety, and increase healthcare efficiency by guiding nurses' decision-making in various healthcare settings. Patient or public contribution was not applicable since the study focused on nurses' decision making.

2024 Guidelines for reporting radiation therapy in veterinary medicine.

Evidence-based medicine drives patient care decision-making; thus, accurate and complete reporting in scientific publications is paramount. A checklist for complete reporting of veterinary radiation therapy was proposed in 2012 using the recommendations of the International Commission of Radiation Units and Measurements (ICRU). The purpose of this study is to review the 2012 checklist and propose updates based on changes in technology. Significant technology advancements have gained traction in veterinary medicine, including intensity-modulated radiation therapy (IMRT) and stereotactic radiation therapy (SRT), both of which have related modality-specific ICRU reporting recommendations. The 2012 checklist and proposed 2024 checklist are then used to assess the completeness of reporting in veterinary radiation oncology publications between 2015 and 2022, of which one hundred and eight publications met the inclusion criteria. Prior to the publication of the 2012 checklist (2005-2010), only nine checklist items showed a good level of completeness in reporting, and from 2015 to 2022, this increased to 16 items. Encouraging and/or requiring the use of reporting checklists at the time of manuscript submission may be responsible for this improvement in reporting. Using the 2024 checklist, which is more relevant to publications discussing IMRT and SRT treatments, only 14 of the analyzed checklist items (34%) show a good level of completeness in reporting, suggesting there is a need for updated guidelines to capture the nuances of advanced techniques. This study proposes a 2024 checklist that can be used as a guideline for future reporting of radiation therapy in veterinary medicine.

Integrating the melanoma 31-gene expression profile test with clinical and pathologic features can provide personalized precision estimates for sentinel lymph node positivity: an independent performance cohort.

Up to 88% of sentinel lymph node biopsies (SLNBs) are negative. The 31-gene expression profile (31-GEP) test can help identify patients with a low risk of SLN metastasis who can safely forego SLNB. The 31-GEP classifies patients as low (Class 1A), intermediate (Class 1B/2A), or high risk (Class 2B) for recurrence, metastasis, and SLN positivity. The integrated 31-GEP (i31-GEP) combines the 31-GEP risk score with clinicopathologic features using a neural network algorithm to personalize SLN risk prediction. Patients from a single surgical center with 31-GEP results were included (n = 156). An i31-GEP risk prediction < 5% was considered low risk of SLN positivity. Chi-square was used to compare SLN positivity rates between groups. Patients considered low risk by the i31-GEP had a 0% (0/30) SLN positivity rate compared to a 31.9% (30/94, p < 0.001) positivity rate in those with > 10% risk. Using the i31-GEP to guide SLNB decisions could have significantly reduced the number of unnecessary SLNBs by 19.2% (30/156, p < 0.001) for all patients and 33.0% (30/91, p < 0.001) for T1-T2 tumors. Patients with T1-T2 tumors and an i31-GEP-predicted SLN positivity risk > 10% had a similar SLN positivity rate (33.3%) as patients with T3-T4 tumors (31.3%). The i31-GEP identified patients with < 5% risk of SLN positivity who could safely forego SLNB. Combining the 31-GEP with clinicopathologic features for a precise risk estimate can help guide risk-aligned patient care decisions for SLNB to reduce the number of unnecessary SLNBs and increase the SLNB positivity yield if the procedure is performed.

Systemic anticancer therapy near the end of life: an analysis of factors influencing treatment in advanced tumor disease

Systemic anticancer treatment (SACT) for advanced cancer patients with limited prognosis before death is associated with high toxicity and reduced quality of life. Guidelines discourage this approach as low-value care. However, a significant number of patients continue to receive SACT in the last 30 days of life. A retrospective study was carried out at the University Hospital Krems, encompassing the analysis of patients who were diagnosed with a solid tumor and died between 2017 and 2021, with a particular focus on the use of end-of-life (EOL) SACT. A total of 685 patients were included in the study. SACT was applied in 342 (49.9%) patients, of whom 143 (41.8%, total population: 20.9%) patients received SACT within the last 30 days of life. Median time from last SACT to death was 44.5 days. The analysis of potential factors impacting the administration of EOL SACT revealed the following significant findings: type of SACT [P < 0.001, targeted therapy odds ratio (OR) 5.09, 95% confidence interval (CI) 2.26-11.48; chemotherapy/targeted therapy OR 3.60, 95% CI 1.47-8.82; immune checkpoint inhibitor OR 2.32, 95% CI 1.37-3.92], no referral to palliative care (PC) (P= 0.009, OR 1.86, 95% CI 1.16-2.96), no admission to PC ward (P < 0.001, OR 2.70, 95% CI 1.67-4.35), and poor Eastern Cooperative Oncology Group (ECOG) performance status (≥2, P < 0.001, OR 3.35, 95% CI 1.93-5.83). The timing of SACT near the EOL is significantly influenced by several factors, including the type of SACT, referral to PC services, admission to PC unit, and ECOG performance status. These findings underscore the complexity of treatment decisions in advanced cancer care and highlight the need for personalized, patient-centered approaches that consider both clinical and patient-related factors to optimize care at the EOL.