Clinicians Deal Research Articles

Индивидуализация гормональной терапии: междисциплинарный подход

Тoday, clinicians deal with many practical issues when prescribing menopausal or hormone replacement therapy. The main goal of the expert workshop was to discuss the principles of prescribing hormone therapy to patients of various age groups with various gynecological and somatic disorders and comorbidities, to determine the tactics for selection of the type of therapy based on the personalization principles.

Artificial intelligence accelerates multi-modal biomedical process: A Survey

The abundance of artificial intelligence AI algorithms and growing computing power has brought a disruptive revolution to the smart medical industry. Its powerful data abstraction and representation capabilities enable the modeling of hundreds of millions of medical data, such as sub-Computed Tomography tumor identification, retinal lesion screening, and survival curve analysis. However, all of these applications demonstrate AI’s use of unimodal data for specific tasks. In contrast, clinicians deal with multi-modal data from multiple sources when diagnosing, performing prognostic assessments, and deciding on treatment plans. These requirements have facilitated the development of multi-modal AI solutions and improved the performance of AI models in handling complex medical scenarios and data. In this paper, we provide an overview of the current state of the art and research in multi-modal biomedical AI, including applications, data, methods, and analytics. Additionally, we summarize potential research directions for multi-modal AI technologies in the future of healthcare.

A dosing strategy model of deep deterministic policy gradient algorithm for sepsis patients

BackgroundA growing body of research suggests that the use of computerized decision support systems can better guide disease treatment and reduce the use of social and medical resources. Artificial intelligence (AI) technology is increasingly being used in medical decision-making systems to obtain optimal dosing combinations and improve the survival rate of sepsis patients. To meet the real-world requirements of medical applications and make the training model more robust, we replaced the core algorithm applied in an AI-based medical decision support system developed by research teams at the Massachusetts Institute of Technology (MIT) and IMPERIAL College London (ICL) with the deep deterministic policy gradient (DDPG) algorithm. The main objective of this study was to develop an AI-based medical decision-making system that makes decisions closer to those of professional human clinicians and effectively reduces the mortality rate of sepsis patients.MethodsWe used the same public intensive care unit (ICU) dataset applied by the research teams at MIT and ICL, i.e., the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) dataset, which contains information on the hospitalizations of 38,600 adult sepsis patients over the age of 15. We applied the DDPG algorithm as a strategy-based reinforcement learning approach to construct an AI-based medical decision-making system and analyzed the model results within a two-dimensional space to obtain the optimal dosing combination decision for sepsis patients.ResultsThe results show that when the clinician administered the exact same dose as that recommended by the AI model, the mortality of the patients reached the lowest rate at 11.59%. At the same time, according to the database, the baseline mortality rate of the patients was calculated as 15.7%. This indicates that the patient mortality rate when difference between the doses administered by clinicians and those determined by the AI model was zero was approximately 4.2% lower than the baseline patient mortality rate found in the dataset. The results also illustrate that when a clinician administered a different dose than that recommended by the AI model, the patient mortality rate increased, and the greater the difference in dose, the higher the patient mortality rate. Furthermore, compared with the medical decision-making system based on the Deep-Q Learning Network (DQN) algorithm developed by the research teams at MIT and ICL, the optimal dosing combination recommended by our model is closer to that given by professional clinicians. Specifically, the number of patient samples administered by clinicians with the exact same dose recommended by our AI model increased by 142.3% compared with the model based on the DQN algorithm, with a reduction in the patient mortality rate of 2.58%.ConclusionsThe treatment plan generated by our medical decision-making system based on the DDPG algorithm is closer to that of a professional human clinician with a lower mortality rate in hospitalized sepsis patients, which can better help human clinicians deal with complex conditional changes in sepsis patients in an ICU. Our proposed AI-based medical decision-making system has the potential to provide the best reference dosing combinations for additional drugs.

Assessing Intracranial Pressure Visualizations Displayed on ICU Bedside Physiologic Monitors

Neurocritical care is considered a complex socio-technical environment where clinicians deal with large amounts of data and need to make timely decisions to provide optimal care for patients, improve outcomes, and reduce mortality. Intracranial pressure (ICP) is one of the key physiologic indicators clinicians track to minimize the risk of secondary brain injury. The understanding and teaching of pathophysiologic ICP trends is perceived as challenging to both novice and advanced clinicians. We propose new ICP visualizations with the goal of facilitating a better understanding of ICP concepts on bedside physiologic monitors to support complex decision-making. We have conducted interviews with clinicians to receive feedback on preliminary designs. Interviews revealed that the staff physician appreciated visualizations with more depth and with calculated parameters to describe the raw data. Contrarily, the trainees and nurses saw the most value in visualizations that were less abstract and easier to interpret.

A systematic review on normal and abnormal anatomy of coronary arteries

Coronary artery (CA) disorders are among the major causes of morbidity and mortality in humans. We attempt to explain CA anatomy and its variations in a simple, concise, and understandable way to help clinicians deal with the various disorders. There are two main arteries: right coronary artery (RCA) and left CA. The left bifurcates into two terminal branches: left anterior descending artery (LAD) and left circumflex artery (LCX). The commonest anatomical variant is trifurcation of left main coronary artery (LMCA) with presence of ramus intermedius artery (RIM), abnormal origin of LCX from RCA or right sinus of Valsalva, abnormal CA origin from unusual aortic sinus in-between aorta and pulmonary trunk, myocardial bridging, CA fistula and aneurysm. The RCA may arise abnormally from the left sinus of Valsalva rather than the usual origin from the right sinus. Furthermore, most cases of abnormal CA fistulas affect the RCA where the artery opens into the right heart chambers, pulmonary trunk, or coronary sinus. Although their incidence is relatively rare, coronary abnormalities are of critical importance in medical practice. Identification of normal and abnormal anatomy of CA is essential because not knowing one of the differences can lead to loss of a person’s life.

Migraine Outcome Should Not Be Used to Determine Diagnosis, Severity, and Therapy: Moving Towards a Multiparametric Definition of Chronicity

Chronic migraine (CM) diagnosis is nowadays based on the threshold of 15 headache days/month for three consecutive months, of which at least eight have migraine headache features. In recent years, proposals for reducing the threshold to 8 days/month have been proposed. The sole frequency parameter, however, is partial considering the variability in frequency, pain severity, associated symptoms, such as nausea, osmophobia, and photophobia, and presence of aura, but also the variable response to treatment and the association with several comorbidities. Therefore, in our opinion, a multiparameter perspective has to be taken into account that considers the underlying pathophysiology, in particular the presence of tension-type-like pain, cutaneous allodynia, and reduced pain threshold. A paradigm change in the definition of chronic migraine moves far beyond the mere 8 vs. 15 days/month, but has ethical and practical implications for treatment: should patients be treated with the most effective prophylactic drugs, i.e., monoclonal antibodies (MABs), if they enter into a new definition of CM? How should clinicians deal with treatment escalation towards MABs? What is the role of associated conditions, response to treatments, lifestyle issues, and psychological factors? And, finally, which endpoint should we use to define effectiveness? Is improvement in headache frequency enough, or should we move towards disability, quality of life, or workplace productivity?

Comparison of various principles of coagulation tests in handling hemolysed blood samples

Background: Rejection of hemolysed samples for coagulation test is the standard practice.However, when clinicians deal with extremely sick patients where repeat sampling is difficult toobtain, rejection of the sample is a lost opportunity for the lab physician to assist inpatient care.Proceeding with the test and providing a clinically helpful interpretation of the results will ensure theactive participation of the laboratory physician. Different principles of coagulation testing handle thehemolysed samples differently. It is essential to know the best principle to proceed with thehemolysed sample if need be. This study set out to estimate the predictive values of post-hemolyticsample coagulation test results with various coagulation test principles. Methods: This is aprospective experimental study where the non-hemolysed samples were processed for coagulationtests. Part of the sample was deliberately hemolysed, and the coagulation tests were repeated.Results: Two hundred and forty-eight samples were studied. A median of 11% hemolysis wasachieved experimentally. The mean difference in prothrombin time between pre and post hemolyticsamples with normal PT was 0.9 and with abnormal PT, it was 1.1 seconds. The same for APTT was4.9 and 1.1 seconds, respectively. The majority of the samples showed prolonged coagulation posthemolysis. Positive (PPV) and negative (NPV) predictive values for prothrombin time are 97.3 and73.4%, respectively. Similarly, PPV and NPV for APTT are 97.4 and 47.1%, respectively.Conclusions: Samples with normal values after hemolysis are more likely to be normal.

Draft of the federal clinical recommendations for diagnosisi and treatment of amiodarone-induced thyroid dysfunction

Amiodarone is an antiarrhythmic drug that is commonly used for treatment of various supraventricular and ventricular arrhythmias. Amiodarone and its main active metabolite desethylamiodarone have a direct dose-dependent cytotoxic effect on thyroid follicular cells. Consequently, some patients receiving amiodarone may develop thyroid dysfunction: amiodarone-induced hypothyroidism (AIH) or amiodarone-induced thyrotoxicosis (AIT). The diagnosis, classification, and treatment of amiodarone-induced thyroid dysfunction remain to be a challenge to all clinicians deal with this problem. This draft of clinical recommendations was developed by a group of specialists experienced in the diagnosis and treatment of amiodarone-induced thyroid dysfunction. AIH does not require amiodarone withdrawal. Thyroxine treatment is recommended for all patients with manifest AIH, subclinical forms of AIH do not always need its prescription. There are two main types of amiodarone-induced thyrotoxicosis: AIT type 1 (is a hyperthyroidism that develops due to excessive iodine intake in autonomous thyroid nodules or latent Graves ‘ disease) and AIT type 2 (develops due to destructive thyroiditis because of the cytotoxic effect of amiodarone). In addition, there is a mixed form, which has features of both types of AIT. Autonomous AIT 1 is characterized by the presence of one or more «hot» nodules in the thyroid. Elevated TSH receptor antibodies or typical clinical manifestations confirm the diagnosis of diffuse toxic goiter and, consequently, AIT1. Colour-flow Doppler sonography (CFDS) is proposed as the basic method of differential diagnosis of AIT 1 and AIT 2. CFDS «pattern 0», usually indicates AIT 2, the presence of «patterns I-III» mostly typical for AIT 1. The thyreostatics are recommended for AIT 1, oral glucocorticoids for AIT 2 and their combination for a mixed AIT. Emergency thyroidectomy should be applied to patients with deteriorating cardiovascular pathology and ineffective drug therapy. In the absence of clinical suspicion on thyroid dysfunction, thyroid hormones assessment should be done 3 months after the start of amiodarone treatment, thereafter every 6 months.

In vitro measurement volume of the neonate thyroid gland

Measurement and replacement fluid methods to estimate the thyroid gland volume. Because there is wideranging of variation in the volume of the thyroid gland in healthy individuals of different geographicallocation, ages, gender, and races.Objectives: To estimate normal neonate thyroid gland volume it can throwlight to help clinicians deal better with the gland during neonatal age besides providing native standarddata. Period: From Sept 13, 2018, to Mar 22, 2019. Material & Methods: Total of 48 subjects wereincluded, 24 male and 24 female. The neonate thyroid gland collected and inspected grossly and taken allmeasurements, then use these measurements for finding volume thyroid gland. Also, the volumeis taken byusing replacement fluid. Results: The mean aggregate thyroid gland volume of measures method for malesubjectsstudy was 250.53 ± 4.37mm3, while a female was 246.31 ± 3.42 mm3. The mean volume thyroidgland of replacement fluid method for male subjects study was 295.71 ± 4.41mm3, while the female was291.43 ± 4.04. The mean thyroid volume of the male is expressively larger than female in both methods butstatically non-significant variation. The difference between both ways statistically highly significant (p<0.01). Conclusion: according to results that achieved by two methods, we should use another correctionfactor, higher than 0.749, until getting the nearest value to replacement fluid. Working out different ages toestablish average data.

Cardiovascular magnetic resonance for the diagnosis and management of heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is characterized by an impaired ventricular filling resulting in the development of dyspnea and other HF symptoms. Even though echocardiography is the cornerstone to demonstrate structural and/or functional alterations of the heart as the underlying cause for the clinical presentation, cardiovascular magnetic resonance (CMR) represents the noninvasive gold standard to assess cardiac morphology, function, and tissue changes. Indeed, CMR allows quantification of biventricular volumes, mass, wall thickness, systolic function, and intra- and extracardiac flows; diastolic functional indices include transmitral and pulmonary venous velocities, left ventricular and left atrial filling velocities from volumetric changes, strain analysis from myocardial tagging, tissue phase contrast, and feature tracking. Moreover, CMR allows superior tissue characterization of the myocardium and the pericardium, which are crucial for a noninvasive etiological and histopathological assessment of HFpEF: conventional T1-weighted, T2-weighted, and post-contrast sequences are now complemented by quantitative mapping sequences, including T1 and T2 mapping as well as extracellular volume quantification. Further experimental sequences comprise diffusion tensor analysis, blood oxygenation-dependent sequences, hyperpolarized contrast agents, spectroscopy, and elastography. Finally, artificial intelligence is beginning to help clinicians deal with an increasing amount of information from CMR exams.

Incidence and risk factors of retinopathy of prematurity in three neonatal intensive care units in Palestine

BackgroundSevere Retinopathy of Prematurity (ROP) is a serious vasoproliferative disorder that can affect extremely premature infants. It continues to be one of the most important preventable causes of blindness in children. Our study is aimed at finding the incidence of ROP and its association with some risk factors in Palestine.MethodsFrom the 1st of January 2016 to 31st December 2016, a total number of 115 infants who met the criteria for ROP screening in three neonatal intensive care units were included in the study. The medical records of infants were reviewed retrospectively and multiple factors that may be associated with the development of ROP were collected manually.ResultsThe incidence of ROP and severe type 1 ROP that require treatment was 23.5 and 11.3% respectively. After conducting univariate analysis of risk factors, statistically significant risk factors affecting the development of ROP in our study were: low gestational age, low birth weight, type of multiple gestation, the presence of affected sibling, low level of Hemoglobin at birth, respiratory distress syndrome, low Hemoglobin level, blood transfusion and days on oxygen supplements with either mechanical, non-mechanical methods or both combined. High bilirubin levels were found as a protective factor against the development of ROP. However, when a multivariate analysis was performed, only low gestational age, total days on oxygen supplement and high bilirubin levels were significant regarding the development of ROP.ConclusionThe incidence of ROP is considered a relatively low percentage compared to neighboring countries that have higher levels of human development index. Statistically significant risk factors need to be considered when clinicians deal with premature infants.

Interactions Between Gut Microbiota and Acute Childhood Leukemia.

Childhood leukemia, the commonest childhood cancer, mainly consists of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Though great progresses have been made in the survival rates of childhood leukemia, the long-term health problems of long-term childhood leukemia survivors remain remarkable. In addition, the deep links between risk factors and childhood leukemia need to be elucidated. What can be done to improve the prevention and the prognosis of childhood leukemia is an essential issue. Gut microbiota, referred to as one of the largest symbiotic microorganisms that is accommodated in the gastrointestinal tract of human or animals, is found to be involved in the progression of various diseases. It is reported that microbiota may keep people in good health by participating in metabolism processes and regulating the immune system. Studies have also explored the potential relationships between gut microbiota and childhood leukemia. This review is meant to illustrate the roles of gut microbiota in the onset of acute childhood leukemia, as well as in the progress and prognosis of leukemia and how the treatments for leukemia affect gut microbiota. Besides, this review is focused on the possibility of building or rebuilding a healthy gut microbiota by adjusting the diet construction so as to help clinicians deal with childhood leukemia.

Anatomical, Histological, Hormonal, And Ultrasonography Study Of Neonate Thyroid Gland

Materials And Methods: The neonate thyroid gland collected and inspected grossly and taken all measurements. Then histologically preparation of the slides and stained with routine Haematoxylin and Eosin (H&E) and special stains for descriptive study. Alive healthy neonates was taken for assessment of thyroid stimulation hormone, in addition the volume by ultrasound and using ellipsoid formula 0.479 as correction factor.
 Results:- Thyroid gland present in lower part of neck anteriorly. Consist from right and left lobes connected via isthmus from lower medial portion of gland. The gland appeared U shape, red brown in color. The mean ±SD Weight 1.35 ±0.34 gram. Dimensions measurement as following, length 12.48 ±1.76, 12.21 ±1.79 for right and left lobes respectively. Width 5.73 ±0.82, 5.88 ±0.73 for right and left lobe. Under light microscope contain large number of follicles larger follicle present on periphery and small in central. The means of TSH in different age groups were had a tendency to decreased as following 10.70 ±3.09 mU/L, 3.55 ±1.81mU/L, 3.30 ±1.61mU/L, and 2.85 ±1.27 mU/L, in male. While in females were 10.90 ±3.19 mU/L, 3.60 ±1.98 mU/L, 3.41 ±1.23 mU/L, and 3.48 ±1.45 mU/L in groups A, B, C, and D, respectively. The total volume of neonates thyroid gland groups in present study in male that were 412.7 ±62.2 mm3, 429.5 ±60.7 mm3, And the total volume in female were 401.2 ±83.9 mm3, 428.6 ±57.8 mm3 for first two groups respectively. The present study aimed to describe normal neonate thyroid gland as Anatomical, Histological, Hormonal, and Sonographical study it can throw light to help clinicians deal better with the gland during neonatal period in addition provide local standard data.

Knowledge, practices and attitudes of physicians towards evidencebased medicine in Egypt.

Evidence-based medicine help clinicians deal with information overload, to distribute healthcare resources more equitably, help reduce healthcare costs, and justify treatment choices to the public. This study aimed to assess evidence-based medicine (EBM) knowledge, practices and attitudes among physicians in Tanta University hospital, Tanta, Egypt. A cross-sectional study was used. Collection of data was by a self-administrated questionnaire distributed to 398 physicians in different specialties during 2017. Response rate was 93.6 %. More than half (61.3 %) of participants reported Pub Med as used in decision-making. Physicians with good knowledge of EBM represented 10.5 %, those with fair knowledge represented 54 %, and those with poor knowledge represented 35.5 %. Regarding attitudes towards EBM, 76.4 % of study participants welcomed the current promotion of EBM; 81.4 % thought that it useful to use research findings in daily management of patients; and 89.9 % thought that practicing EBM improved patient outcomes. More than half of participants (55.8 %) had attended courses related to EBM, but only 6.8 % had attended courses related to critical appraisal. The majority of participants (97 %) had access to the World Wide Web. Barriers reported by participants that interfere with EBM practice were patient overload (68.1 %), lack of time (60.1 %), colleagues' attitudes (47 %), lack of skills (46.7 %), and fear of criticism (44.5 %). Most participants in this study have a positive attitude towards EBM, have a fair knowledge of it, but poor practices. EBM should be integrated in the curriculum of both undergraduate and postgraduate studies, and EBM training courses provided to residents to ensure correct application of EBM in daily practice.

An automated pipeline for analyzing\xa0medication event reports in clinical settings

BackgroundMedication events in clinical settings are significant threats to patient safety. Analyzing and learning from the medication event reports is an important way to prevent the recurrence of these events. Currently, the analysis of medication event reports is ineffective and requires heavy workloads for clinicians. An automated pipeline is proposed to help clinicians deal with the accumulated reports, extract valuable information and generate feedback from the reports. Thus, the strategy of medication event prevention can be further developed based on the lessons learned.MethodsIn order to build the automated pipeline, four classic machine learning classifiers (i.e., support vector machine, Naïve Bayes, random forest, and multi-layer perceptron) were compared to identify the event originating stages, event types, and event causes from the medication event reports. The precision, recall and F-1 measure were calculated to assess the performance of the classifiers. Further, a strategy to measure the similarity of medication event reports in our pipeline was established and evaluated by human subjects through a questionnaire.ResultsWe developed three classifiers to identify the medication event originating stages, event types and causes, respectively. For the event originating stages, a support vector machine classifier obtains the best performance with an F-1 measure of 0.792. For the event types, a support vector machine classifier exhibits the best performance with an F-1 measure of 0.758. And for the event causes, a random forest classifier reaches an F-1 measure of 0.925. The questionnaire results show that the similarity measurement is consistent with the domain experts in the task of identifying similar reports.ConclusionWe developed and evaluated an automated pipeline that could identify three attributes from the medication event reports and calculate the similarity scores between the reports based on the attributes. The pipeline is expected to improve the efficiency of analyzing the medication event reports and to learn from the reports in a timely manner.

Female psychopharmacology matters! Towards a sex-specific psychopharmacology.

There is increasing recognition that women have a higher prevalence of certain psychiatric illnesses, and a differential treatment response and course of illness compared to men. Additionally, clinicians deal with a number of disorders like premenstrual syndrome, premenstrual dysphoric disorder, and postpartum depression, which affect women specifically and for which treatment and biological pathways are still unclear. In this article we highlight recent research which suggests that different biological mechanisms may underlie sex differences in responsiveness to stress. Sex differences are evident at the receptor level; where the corticotropin-releasing factor receptor shows differential coupling to adaptor proteins in males and females. The neuropeptide oxytocin also shows sex-specific effects in a range of social behaviors. It may act as a biomarker in post-traumatic stress disorder where sex differences are evident. Studies in women using hormonal contraception show that some of these oxytocin-mediated effects are likely influenced by sex hormones. In female rats rapid changes in circulating progesterone levels are associated with exaggerated behavioral responses to mild stress and blunted responses to benzodiazepines that could be prevented by acute treatment with low-dose fluoxetine. Perceived barriers in research on women have hindered progress. The development of a sex-specific psychopharmacology as a basis for translating this type of research into clinical practice is vital to improve treatment outcomes for women.

Learning lessons from diabetes emergencies

Health care in the 21st century is complex. Clinicians deal with the challenges of an ageing population and care for people with multiple comorbidities including dementia. People receiving health care are vulnerable and organisations must ensure that patient safety issues are addressed. When incidents occur organisations must learn lessons and ensure that changes are made to reduce future risks and improve care. Nurses working at advanced level are in a unique position to contribute to this process by working with staff from the ward to the Trust board and drive change to ensure that we continue to develop an effective safety culture.

Reflections on an academic career.

There are many undefined aspects to an academic medical career. This article attempts to provide some guidance about things to consider.

\u201cI\u2019d been like freaking out the whole night\u201d: exploring emotion regulation based on junior doctors\u2019 narratives

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross’ theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross’ theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students’ awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

Whose decision is it anyway? A qualitative study of user participation and how clinicians deal with the patient perspective in mental healthcare

Purpose The concept of user participation is well accepted internationally. Nevertheless, studies show that both patients and health professionals find it challenging to maintain patient-centred ideals in the context of severe mental illness. The purpose of this paper is to explore how professionals deal with the ideals in light of patients’ right to participate in planning and decision making regarding milieu therapeutic measures and activities. Design/methodology/approach This is a qualitative study with an interactionist approach based on fieldwork at three district psychiatric centres in Norway during 2011-2012. The observations focused on patient-staff interaction in milieu therapeutic activities. Interviews were based on observed situations. Findings Adherence to treatment, rules and routines restricted patient autonomy. The professionals’ practical orientation towards routines overrode the ideals of patients’ rights. The staff regarded user participation primarily as participation in organised and mandatory activities. Refusal to comply was met with different sanctions, e.g. the prospect of being discharged. Originality/value Although user participation calls for patient-centred approaches, there is some debate about the challenges and premises for cooperation with persons suffering from severe mental conditions. This study adds insight into the everyday organisational context that facilitates or impedes user participation. It helps to explain why the user perspective can be overlooked, thus providing important information to both clinicians and policy makers who aim to fulfil the patient’s right to participate in planning and decision making regarding treatment and care.