Clinical Decision Tool Research Articles

A clinical decision tool to manage tooth-supported fixed partial denture biological complications.

A clinical decision tool to manage tooth-supported fixed partial denture biological complications.

Defining a radiomics feature selection method for predicting response to transarterial chemoembolization in hepatocellular carcinoma patients

AimTo assess the utility of different radiomics feature selection methods in predicting transarterial chemoembolization (TACE) response in hepatocellular carcinoma (HCC) patients. Materials and methodsThis study employed a dataset of 136 paired MR T1-weighted contrast-enhanced abdominal images with liver tumor masks before and after TACE. TACE response for each image pair was classified by European Association for the Study of the Liver (EASL) and modified Response Evaluation Criteria in Solid Tumors (mRECIST) guidelines. 100D feature vectors were generated for the paired tumor areas. Eighteen existing feature selection methods were employed to select the top-k features to train and test a non-linear support vector machine (SVM) with a Gaussian kernel. Five-cross validation was performed to identify the highest performing feature selection methods. ResultsFor all benchmarks, a L0-based method selecting the top-5 or top-10 features achieved the highest performance. For images classified with EASL criteria that were analyzed with the L0-based method, the accuracy (ACC), area under curve (AUC), and balanced F score (F1-score) were 0.75 ​± ​0.06, 0.75 ​± ​0.09, and 0.80 ​± ​0.05, respectively. For images classified with mRECIST criteria that were analyzed with the L0-based method, the ACC, AUC, and F1-score were 0.75 ​± ​0.07, 0.71 ​± ​0.16, and 0.82 ​± ​0.04, respectively. ConclusionA L0-based method that selected the top-5/10 most important features predicted TACE response in HCC patients with the highest accuracy under both EASL and mRECIST criteria. This proof-of-concept investigation represents a step forward in the development of a reliable clinical decision-making tool for management of intermediate HCC patients undergoing TACE.

An online clinical decision tool to screen for vertebral fragility fractures (Vfrac) in older women presenting with back pain in general practice: protocol for a feasibility study in preparation for a future cluster randomised controlled trial

SummaryThis feasibility study for a future definitive randomized trial assesses the use and acceptability of a new clinical decision tool to identify risk of a vertebral fracture and those who should be referred for spinal radiography in women aged 65 or over presenting to primary care with back pain.PurposeApproximately 12% of older adults have vertebral fragility fractures, but currently fewer than one-third are diagnosed, potentially limiting access to bone protection treatment. Vfrac is a vertebral fracture screening tool which classifies individuals into high or low risk of having a vertebral fracture, allowing targeting of spinal radiographs to high-risk individuals. The objective of this study was to investigate the feasibility of conducting a cluster randomized controlled trial to evaluate the use of an online version of Vfrac in primary care.MethodsThe study will run in six general practices, with three given the Vfrac tool for use on older women (> 65 years) consulting with back pain and three using standard clinical processes for managing such back pain. Anonymised data covering a 12-month period will be collected from all sites on consultations by older women with back pain. Focus groups will be undertaken with healthcare professionals and patients on whom the tool was used to understand the acceptability of Vfrac and identify factors that impact its use. These patients will be sent a paper version of the Vfrac questionnaire to self-complete at home. Outputs of the self-completion Vfrac (high versus low risk) will be compared with the face-to-face Vfrac (high versus low risk), and agreement assessed using Cohen’s kappa.ResultsThis study will evaluate the use and acceptability of Vfrac within primary care and determine if data on resource use can be collected accurately and comprehensively.ConclusionsThis article describes the protocol of the Vfrac feasibility study.Trial registrationISRCTN18000119 (registered 01/03/2022) and ISRCTN12150779 (registered 10/01/2022).

Development of a reference interval for urinary ammonia-to-creatinine ratio in feline patients.

Disruption of acid-base homeostasis can lead to many clinical problems. Ammonia excretion by the kidneys is critical to maintaining acid-base homeostasis through bicarbonate production. Measurement of ammonia excretion may help determine if the kidneys are properly functioning in maintaining acid-base balance. Reference intervals are essential tools for clinical decision-making but do not currently exist for urinary ammonia-to-creatinine ratio (UACR) in feline patients. This study aimed to generate a reference interval (RI) for UACR in healthy adult cats. The study used samples from client-owned adult healthy cats that presented to the University of Florida Primary Care and Dentistry service (n = 92). Physical examination, serum biochemistry, urinalysis, urine ammonia, and creatinine concentrations were measured. Cats were excluded if there were significant abnormalities in their urinalysis or biochemistry panel. The RI for UACR was calculated according to the recommendation of the American Society for Veterinary Clinical Pathology. The UACR was evaluated for correlation with serum bicarbonate, weight, age, and sex. The RI for UACR was 3.4-20.7 with 90% confidence intervals for the lower and upper limits of (3.0-3.7) and (16.0-23.7), respectively. No significant correlation with age, sex, or weight was found. There was no discernable relationship between serum bicarbonate and UACR. Establishing an RI for UACR in healthy adult cats will allow further studies to determine if changes in UACR are observed during specific disease states.

A Spherical Cap Model of Epidural Hematomas.

Background Epidural hematomas (EDHs), which have a characteristic biconvex shape, are a type of post-traumatic intracranial mass. EDHs and other types of intracranial hematomas are often diagnosed with computed tomography (CT). The volumes of EDHs are important in treatment decisions and prognosis. Their volumes are usually estimated on CT using the "ABC" method, which is based on the ellipsoid shape rather than their biconvex shape. Objective To simulate the biconvex shape, we modeled the geometry of EDHs with two spherical caps. We aim to provide simpler estimation of EDH volumes in clinical settings, and eventually recommend a threshold for surgical evacuation. Methods Applying the relationship between the sphere radius, spherical cap height, and base circle radius, we derived formulas for the shape of an EDH, relating its largest diameter and location to the other two diameters. We also estimated EDH volumes using the spherical cap volume and conventional ABC formulas and then constructed a lookup table accordingly. Results Validation of the model was performed using 14 CT image sets from previously reported patients with EDHs. Our geometric model demonstrated accurate predictions. Themodel also allows reducing the number of parameters to be measured in the ABC method from three to one, the hematoma length, showcasing its potential as a reliable tool for clinical decision-making. Based on our model, an EDH longer than 7 cm would occupy more than 30 mL of the intracranial volume. Conclusion The proposed model offers a streamlined approach to estimating EDH volumes, reducing the complexity of parameters required for clinical assessments. We recommend a length of 7 cm as a threshold for surgical evacuation of EDHs. This acceleration in decision-making is crucial for managing critically injured patients with traumatic brain injuries. Further validation across diverse patient populations will enhance the generalizability and utility of this geometric modeling approach in clinical settings.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

ObjectiveHospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to...

Development of a Soft Tissue Knee Clinical Decision-Making Tool for Patients Presenting to Primary Point-of-Care Providers in Alberta, Canada.

Several barriers exist in Alberta, Canada to providing accurate and accessible diagnoses for patients presenting with acute knee injuries and chronic knee problems. In efforts to improve quality of care for these patients, an evidence-informed clinical decision-making tool was developed. Forty-five expert panelists were purposively chosen to represent stakeholder groups, various expertise, and each of Alberta Health Services' 5 geographical health regions. A systematic rapid review and modified Delphi approach were executed with the intention of developing standardized clinical decision-making processes for acute knee injuries, atraumatic/overuse conditions, knee arthritis, and degenerative meniscus. Standardized criteria for screening, history-taking, physical examination, diagnostic imaging, timelines, and treatment were developed. This tool standardizes and optimizes assessment and diagnosis of acute knee injuries and chronic knee problems in Alberta. This project was a highly collaborative, province-wide effort led by Alberta Health Services' Bone and Joint Health Strategic Clinical Network (BJH SCN) and the Alberta Bone and Joint Health Institute (ABJHI).

Stratification of patients with idiopathic Rem Behavior Disease patients (iRBD) based on principal component analysis and multivariate machine learning models: an useful statistical tool for clinical decision making in Parkinson’s disease

Stratification of patients with idiopathic Rem Behavior Disease patients (iRBD) based on principal component analysis and multivariate machine learning models: an useful statistical tool for clinical decision making in Parkinson’s disease

Defining Melanoma Immune Biomarkers-Desert, Excluded, and Inflamed Subtypes-Using a Gene Expression Classifier Reflecting Intratumoral Immune Response and Stromal Patterns.

The spatial distribution of tumor infiltrating lymphocytes (TILs) defines several histologically and clinically distinct immune subtypes-desert (no TILs), excluded (TILs in stroma), and inflamed (TILs in tumor parenchyma). To date, robust classification of immune subtypes still requires deeper experimental evidence across various cancer types. Here, we aimed to investigate, define, and validate the immune subtypes in melanoma by coupling transcriptional and histological assessments of the lymphocyte distribution in tumor parenchyma and stroma. We used the transcriptomic data from The Cancer Genome Atlas melanoma dataset to screen for the desert, excluded, and inflamed immune subtypes. We defined subtype-specific genes and used them to construct a subtype assignment algorithm. We validated the two-step algorithm in the qPCR data of real-world melanoma tumors with histologically defined immune subtypes. The accuracy of a classifier encompassing expression data of seven genes (immune response-related: CD2, CD53, IRF1, and CD8B; and stroma-related: COL5A2, TNFAIP6, and INHBA) in a validation cohort reached 79%. Our findings suggest that melanoma tumors can be classified into transcriptionally and histologically distinct desert, excluded, and inflamed subtypes. Gene expression-based algorithms can assist physicians and pathologists as biomarkers in the rapid assessment of a tumor immune microenvironment while serving as a tool for clinical decision making.

Consensus for a primary care clinical decision-making tool for assessing, diagnosing, and managing low back pain in Alberta, Canada.

Low back pain (LBP) is a common condition causing disability and high healthcare costs. Alberta faces challenges with unnecessary referrals to specialists and long wait times. A province-wide standardized clinical care pathway based on evidence-based best practices can improve efficiency, reduce wait times, and enhance patient outcomes. Implementing such pathways has shown success in other areas of healthcare in Alberta. This study developed a clinical decision-making pathway to standardize care and minimize uncertainty in assessment, diagnosis, and management. A systematic rapid review identified existing tools and evidence that could support a comprehensive LBP clinical decision-making tool. Forty-seven healthcare professionals participated in four rounds of a modified Delphi approach to reach consensus on the assessment, diagnosis, and management of patients presenting to primary care with LBP in Alberta, Canada. This project was a collaborative effort between Alberta Health Services' Bone and Joint Health Strategic Clinical Network (BJHSCN) and the Alberta Bone and Joint Health Institute (ABJHI). A province-wide expert panel consisting of professionals from different health disciplines and regions collaborated to develop an LBP clinical decision-making tool. This tool presents clinical care pathways for acute, subacute, and chronic LBP. It also provides guidance for history-taking, physical examination, patient education, and management. This clinical decision-making tool will help to standardize care, provide guidance on the diagnosis and management of LBP, and assist in clinical decision-making for primary care providers in both public and private sectors.

P300 An Expert Delphi Consensus: Early Identification of Patients at Risk of Crohn's Disease in Perianal Fistulas and Abscesses (PREFAB) and Identification and Management of Isolated Perianal Crohn's Disease (ipCD) - Part A, PREFAB

Abstract Background In ± 10% of all Crohn’s disease (CD) patients a perianal abscess (PAA) or fistula (PAF) is the manifesting symptom. The delay in diagnosis of CD, from fistula or abscess onset, is very long and associated with worse outcomes. The aim of this Delphi study was to reach consensus on a clinical decision tool to help select patients with raised suspicion of CD in PAA/PAF patients, to identify underlying CD earlier and reduce the diagnostic delay. Methods A panel of international experts in the field of proctology and/or Inflammatory Bowel Disease (IBD), consisting of surgeons, gastroenterologists and radiologists were invited to participate in the PREFAB part of this Delphi study. The first round was an electronic survey and the second round a virtual consensus meeting. In the first round, participants were asked to anonymously provide their opinion probing 1) the relevance and use of clinical characteristics (“Red Flags”) suggestive of underlying CD, 2) the use of faecal calprotectin (FCP) as an adjunct for screening for CD and 3) on the diagnostic work-up for IBD in PAA/PAF patients with raised clinical suspicion. In the second round, statements were paired/revised based on the feedback from the first round and presented in a final set of statements. Consensus was predefined as ≥70% agreement. Results A total of 30 experts participated in the first round and 25 in the second round (83.3%). Final consensus was reached for 29% of all statements in the first Delphi round and, after adjustments/merging, for all 11 statements (100%) in the second round. Ninety-seven percent of participants agreed that shortening of the delay in diagnosis by using a clinical decision tool could improve outcomes in patients with perianal disease as a first symptom. Consensus was reached on the red flags to be included in the clinical decision tool, on screening of all patients with any perianal fistula (regardless of the complexity, biological behaviour and co-existent perianal symptoms) to identify CD in an early (sub)clinical phase, on referral criteria and on the diagnostic workup and follow up of patients with raised suspicion. Conclusion A clinical decision tool for early identification of CD in patients with PAA/PAF as a first symptom could shorten delay in diagnosis and improve outcomes. Global consensus for this tool, including a practical and relevant algorithm for finding or excluding CD in patients with PAA/PAF as a manifesting sign, was reached within two rounds. This clinical decision tool will be validated in 2024 in a large, prospective multicenter study.

Examining clinicians' perceptions and experiences working with diverse families in family-based treatment: Common adaptations and considerations for treatment engagement.

Family-Based Treatment (FBT) is the leading manualized treatment for adolescent eating disorders; however, there is limited research on the adaptation of FBT for diverse families (i.e., families belonging to identity groups subject to systemic barriers and prejudices). The purpose of this qualitative study was to address: (1) adaptations made to the FBT model (if any) by clinicians working with diverse youth and families; (2) the barriers/facilitators of maintaining adherence (fidelity) to the model for these families; and, (3) the barriers/facilitators to access and engagement in FBT for diverse families. Forty-one FBT clinicians were recruited globally using purposive and snowball sampling, and listservs from eating disorder networks. Clinicians participated in individual interviews or focus groups, discussing their experiences delivering and adapting FBT for diverse families. Qualitative data was transcribed verbatim and analyzed using directed content analysis. Some participants reported making adaptations to every phase of the FBT model, while others did not, when working with diverse families. In Phase 1, participants cited adapting the family meal, length/number of sessions provided, and addressed systemic barriers. In Phase 2, participants adapted the length of the phase and rate/level of independence given back to the adolescent. In Phase 3, participants increased or decreased the number of sessions, or eliminated this phase to address barriers to engagement in FBT. This is the first study to qualitatively examine clinicians' experiences of implementing FBT with diverse families. Results may inform future FBT planning, clinician training, clinical decision-making tools, and opportunities for modifications to the foundational model. This qualitative study examined clinicians' perceptions and experiences implementing FBT with diverse families, specifically what adaptations (if any) were made to the foundational model, and the barriers and facilitators to adhering to and engaging in the model. Results show that some participants reported making adaptations to every phase of FBT, while others did not, with diverse families. Findings may inform future treatment planning, clinician training, clinical decision-making tools, and potential modifications to FBT.

Dual-modal radiomics nomogram based on contrast-enhanced ultrasound to improve differential diagnostic accuracy and reduce unnecessary biopsy rate in ACR TI-RADS 4–5 thyroid nodules

BackgroundAmerican College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS, TR) 4 and 5 thyroid nodules (TNs) demonstrate much more complicated and overlapping risk characteristics than TR1-3 and have a rather wide range of malignancy possibilities (> 5%), which may cause overdiagnosis or misdiagnosis. This study was designed to establish and validate a dual-modal ultrasound (US) radiomics nomogram integrating B-mode ultrasound (BMUS) and contrast-enhanced ultrasound (CEUS) imaging to improve differential diagnostic accuracy and reduce unnecessary fine needle aspiration biopsy (FNAB) rates in TR 4–5 TNs.MethodsA retrospective dataset of 312 pathologically confirmed TR4-5 TNs from 269 patients was collected for our study. Data were randomly divided into a training dataset of 219 TNs and a validation dataset of 93 TNs. Radiomics characteristics were derived from the BMUS and CEUS images. After feature reduction, the BMUS and CEUS radiomics scores (Rad-score) were built. A multivariate logistic regression analysis was conducted incorporating both Rad-scores and clinical/US data, and a radiomics nomogram was subsequently developed. The performance of the radiomics nomogram was evaluated using calibration, discrimination, and clinical usefulness, and the unnecessary FNAB rate was also calculated.ResultsBMUS Rad-score, CEUS Rad-score, age, shape, margin, and enhancement direction were significant independent predictors associated with malignant TR4-5 TNs. The radiomics nomogram involving the six variables exhibited excellent calibration and discrimination in the training and validation cohorts, with an AUC of 0.873 (95% CI, 0.821–0.925) and 0.851 (95% CI, 0.764–0.938), respectively. The marked improvements in the net reclassification index and integrated discriminatory improvement suggested that the BMUS and CEUS Rad-scores could be valuable indicators for distinguishing benign from malignant TR4-5 TNs. Decision curve analysis demonstrated that our developed radiomics nomogram was an instrumental tool for clinical decision-making. Using the radiomics nomogram, the unnecessary FNAB rate decreased from 35.3 to 14.5% in the training cohort and from 41.5 to 17.7% in the validation cohorts compared with ACR TI-RADS.ConclusionThe dual-modal US radiomics nomogram revealed superior discrimination accuracy and considerably decreased unnecessary FNAB rates in benign and malignant TR4-5 TNs. It could guide further examination or treatment options.

A Comprehensive Study on Tear Meniscus Height Inter-Eye Differences in Aqueous Deficient Dry Eye Diagnosis

(1) Background: Dry eye disease (DED) is a chronic ocular surface condition that requires precise diagnostic tools. The present study aimed to investigate the diagnostic potential of the absolute inter-eye difference (|OD-OS|) in tear meniscus height (TMH) for the detection of the presence of aqueous deficient dry eye (ADDE). (2) Methods: A sample of 260 participants with dry eye complaints underwent ocular surface examinations thorough diagnostic assessments based on the Tear Film and Ocular Surface Society guidelines (TFOS DEWS II). Participants were subsequently categorized as No ADDE and ADDE based on TMH. Statistical analyses to determine the optimal TMH|OD-OS| cut-off value in a randomly selected study group (200 participants) were performed, while a separate validation analysis of the cut-off value obtained in a random cross-validation group (60 participants) was also performed. (3) Results: The significant diagnostic capability of TMH|OD-OS| (area under the curve = 0.719 ± 0.036, p < 0.001) was found. The identified cut-off value of 0.033 mm demonstrated reliable specificity (77.6%) and moderate sensitivity (59.1%). Cross-validation confirmed the cut-off value’s association with the TFOS DEWS II diagnostic criterion (Cramer’s V = 0.354, p = 0.006). (4) Conclusions: The present study provides evidence for the diagnostic potential of TMH|OD-OS| in identifying ADDE. The identified cut-off value enhances the specificity and offers moderate sensitivity, providing an objective tool for clinical decision making.

Consistency and heterogeneity of microsatellite instability (MSI) status in paired biopsy and surgical specimens of colorectal cancer: A necessity for MSI reassessment after treatment?

149 Background: Microsatellite instability (MSI) plays a crucial role as a cancer immunotherapy and prognosis biomarker, making accurate MSI detection essential. However, currently, there is still a lack of available data on the impact of neoadjuvant therapy on MSI status, as well as validated data on standardized methods for MSI testing in small biopsy samples. The study aimed to investigate the concordance of MSI status between paired biopsy and surgical samples, as well as the impact of neoadjuvant therapy on MSI status using a novel MSI next-generation sequencing (MSI-NGS) detection panel. Methods: A total of 137 colorectal cancer (CRC) patients were enrolled for this study, of whom 116 with paired biopsy and surgical samples were analyzed. A custom MSI-NGS panel was employed and its performance was compared to MSI polymerase chain reaction (MSI-PCR), which served as the gold standard. Results: Out of the 116 cases, 112 patients showed consistent MSI status between biopsy and surgical samples, with an overall accuracy of 97% regardless of the detection method used. In the cases with MSI discrepancy (6 cases), 83% (5/6) of the patients showed a transition from MSS to MSI-H from biopsy to surgery. Interestingly, all eight patients who received neoadjuvant chemotherapy maintained an unchanged MSI status. However, in one patient who received adjuvant treatment and underwent a repeat biopsy after surgery, the MSI status exhibited alterations. Further analysis of clonal evolution revealed that this heterogeneity stemmed from the disappearance of the original clones and the emergence of new clones. Additionally, the NGS panel exhibited strong concordance with MSI-PCR and high accuracy, sensitivity and specificity with an AUC of 0.942 after rigorous validation. Conclusions: The study revealed a high concordance in MSI status between paired biopsy and surgical samples by employing a custom MSI-NGS panel for MSI status detection, providing reliable basis for further research in this field. Moreover, neoadjuvant chemotherapy seemed to have no impact on MSI status in our study, whereas postoperative adjuvant chemotherapy may influence changes in MSI status, highlighting the necessity of reevaluating MSI status after surgery. The findings also underscore the potential of NGS-based MSI detection as a valuable tool for clinical decision-making.

Survival nomograms for vulvar squamous cell carcinoma based on the SEER database and a Chinese external validation cohort.

The aim of study was to construct a nomogram to effectively predict the overall survival (OS) and cancer-specific survival (CSS) for patients with vulvar squamous cell carcinoma (VSCC). The training cohort consisted of 5405 patients with VSCC, extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. Eighty-four patients with VSCC were selected from the disease database of the Shengjing Hospital of China Medical University from 2014 to 2020, and enrolled as the external validation cohort. Significant independent prognostic factors were identified using Cox regression analysis and used to develop nomograms to predict 1-, 3-, and 5-year OS and CSS in patients with VSCC. The nomogram predicting OS was developed based on tumor size, histological grade, International Federation of Gynecology and Obstetrics (FIGO) stage, regional lymph node involvement, distant metastases, surgery, chemotherapy, age, and race. The nomogram for CSS was constructed using the similar factors, excluding race but including marital status. The nomogram for 1-, 3-, and 5-year OS demonstrated robust performance with receiver operating characteristic curves (AUCs) exceeding 80% (0.86, 0.84, and 0.82), outperforming the FIGO staging alone (0.77, 0.75, and 0.72). Similarly, for CSS, our nomograms achieved larger AUCs of 0.89, 0.88, and 0.86 compared with FIGO staging alone (0.81, 0.79, and 0.78). The nomograms more accurately predict prognosis than simple FIGO staging. Moreover, the nomograms developed in this study provide a convenient, operable, and reliable tool for individual assessment and clinical decision-making for patients with VSCC.

Determining a urinary-specific antibiogram and risk factors of trimethoprim/sulfamethoxazole, ciprofloxacin and multidrug resistance among Enterobacterales in primary care.

Risk factors for ciprofloxacin or MDR in primary care urine specimens are not well defined. We created a primary care-specific antibiogram for Escherichia coli isolates from cases with complicated and uncomplicated urinary tract infection (UTI) and evaluated risk factors for ciprofloxacin, trimethoprim/sulfamethoxazole and MDR among Enterobacterales. We conducted a cross-sectional study to determine resistance and risk factors by collecting urine cultures from all patients (≥18 years) presenting with provider-suspected UTI at two primary care, safety-net clinics in Houston, TX, USA between November 2018 and March 2020. Among 1262 cultures, 308 cultures grew 339 uropathogens. Patients with Enterobacterales (n = 199) were mostly female (93.5%) with a mean age of 48.5 years. E. coli was the predominant uropathogen isolated (n = 187/339; 55%) and had elevated trimethoprim/sulfamethoxazole (43.6%) and ciprofloxacin (29.5%) resistance, low nitrofurantoin (1.8%) resistance, and no fosfomycin resistance. Among E. coli, 10.6% were ESBL positive and 24.9% had MDR. Birth outside the U.S.A., prior (2 year) trimethoprim/sulfamethoxazole resistance, and diabetes mellitus were associated with trimethoprim/sulfamethoxazole resistance. Prior (60 day) fluoroquinolone use, prior ciprofloxacin resistance and both diabetes mellitus and hypertension were strongly associated with ciprofloxacin resistance. Prior fluoroquinolone use and a history of resistance to any studied antibiotic were associated with MDR, while pregnancy was protective. We found elevated resistance to UTI-relevant antimicrobials and novel factors associated with resistance; these data can be incorporated into clinical decision tools to improve organism and drug concordance.

The Challenges of Implementing and Documenting Ottawa Ankle Rules in the Pediatric Emergency Department: A Retrospective Study

INTRODUCTION Acute ankle sprains account for nearly 2% of visits to the pediatric emergency department (PED). The Ottawa Ankle Rules (OAR) were developed as a safe and effective clinical decision-making tool for detecting the need for radiographs in adults with acute ankle pain. OAR state radiographs are required with at least one of the following: 1. Inability to bear weight immediately following the injury and for four steps in the ED 2. Bony tenderness at the posterior edge of the lateral or medial malleolus OBJECTIVE Few prospective cohort studies have attempted to assess OAR pediatric populations. This study investigates the validity and documentation of OAR within a single academic institution’s PED. METHODS This retrospective chart review included previously healthy patients aged 2-19 years who presented to the PED with a traumatic ankle injury between 2019 and 2021. Exclusion criteria were met with documented parental insistence for imaging studies. We compared calculated OAR predictive values to those in literature using Chi-squared tests and WINPEPI. RESULTS A total of 295 subjects were included. When only considering clinically significant fractures in the data analysis, 247 patients received X-rays and 42 clinically significant fractures were found. OAR were 100% sensitive (95% confidence interval 93.1–100.0), 12.2% specific (95% CI 8.2–17.2), with a positive predictive value (PPV) of 18.9% (95% CI 16.6–26.5), and negative predictive value (NPV) of 100% (95% CI 88.7–100.0). When comparing this study’s findings to those with similar design protocol, specificity was lower (p<0.05) and there was no significant difference in sensitivity, PPV, or NPV. CONCLUSION Implementing the highly sensitive OAR yielded zero missed fractures. Their poor specificity results in unnecessary radiation exposure, which also increases expense and wait time. Excess imaging may be attributed to ambiguous OAR criteria, their dependence on pediatric cooperation, and parental expectations for imaging studies.

Clinical Characteristics and Nomogram for Predicting Mortality in Patients with Postoperative Bloodstream Infection in Surgical Intensive Care Unit.

Bloodstream infection is amongst the leading causes of mortality for critical postoperative patients. However, data, especially from developing countries, are scary. Clinical decision-making tools for predicting postoperative bloodstream infection-related mortality are important but still lacking. To analyze the distribution of pathogens and develop a nomogram for predicting mortality in patients with postoperative bloodstream infection in the surgical intensive care unit. The clinical data, infection and pathogen-related data, and prognosis of patients with PBSI in the SICU from January 2017 to January 2022 were retrospectively collected. The distribution of pathogens and clinical characteristics of patients with PBSI were analyzed. The patients were assigned to a died group and a survived group according to their survival status. Independent predictors for mortality were identified by univariate and multivariate analyses. A nomogram for predicting PBSI-related death was developed based on these independent predictors. Calibration and decision-curve analysis were established to evaluate the nomogram. We collected postoperative patients admitted to our center from February 2022 to June 2023 as external validation sets to verify the nomogram. We also add the Brier score to further validate the model. In the training set, 7128 patients admitted to the SICU after different types of surgery were collected. A total of 198 patients and 308 pathogens were finally enrolled. The mean age of patients with PBSI was 64.38 ± 16.22 (range 18-90) years, and 56.1% were male. Forty-five patients (22.7%) died in the hospital. Five independent predictors including BMI, APACHE II score, estimated glomerular filtration rate (eGFR), urine volume in the first 24 hours after surgery, and peak temperature before positive blood cultures were selected to establish the nomogram. The area under the receiver operating characteristic curve for the prediction model was 0.922. Calibration curve and decision curve analysis showed good performance of the nomogram. Seventy patients with PBSI were collected as an external validation set, and thirteen patients died in this set. The external validation set was used to validate the nomogram, and the results showed that the AUC was 0.930 which was higher than that in the training set indicating that the nomogram had a good discrimination. The brier score was 0.087 for training set and 0.050 for validation set. PBSI was one of the key issues that clinicians were concerned and could be assessed with a good predictive model using simple clinical factors.

Comprehensive biomechanical and anatomical atherosclerotic plaque metrics predict major adverse cardiovascular events: A new tool for clinical decision making

Background and aimsAnatomical imaging alone of coronary atherosclerotic plaques is insufficient to identify risk of future adverse events and guide management of non-culprit lesions. Low endothelial shear stress (ESS) and high plaque structural stress (PSS) are associated with events, but individually their predictive value is insufficient for risk prediction. We determined whether combining multiple complementary, biomechanical and anatomical plaque characteristics improves outcome prediction sufficiently to inform clinical decision-making. MethodsWe examined baseline ESS, ESS gradient (ESSG), PSS, and PSS heterogeneity index (HI), and plaque burden in 22 lesions that developed subsequent events and 64 control lesions that remained quiescent from the PROSPECT study. Results86 fibroatheromas were analysed from 67 patients. Lesions with events showed higher PSS HI (0.32 vs. 0.24, p<0.001), lower local ESS (0.56Pa vs. 0.91Pa, p = 0.007), and higher ESSG (3.82 Pa/mm vs. 1.96 Pa/mm, p = 0.007), while high PSS HI (hazard ratio [HR] 3.9, p = 0.006), high ESSG (HR 3.4, p = 0.007) and plaque burden>70 % (HR 2.6, p = 0.02) were independent outcome predictors in multivariate analysis. Combining low ESS, high ESSG, and high PSS HI gave both high positive predictive value (80 %), which increased further combined with plaque burden>70 %, and negative predictive value (81.6 %). Low ESS, high ESSG, and high PSS HI co-localised spatially within 1 mm in lesions with events, and importantly, this cluster was distant from the minimum lumen area site. ConclusionsCombining complementary biomechanical and anatomical metrics significantly improves risk-stratification of individual coronary lesions. If confirmed from larger prospective studies, our results may inform targeted revascularisation vs. conservative management strategies.