Criteria For Clinical Decision-making Research Articles

Bone reconstruction of extensive maxillomandibular defects in adults.

Reconstruction of significant maxillomandibular defects is a challenge that has been much discussed over the last few decades. Fundamental principles were developed decades ago (bone bed viability, graft immobilization). Clinical decision-making criteria are highly relevant, including local/systemic factors and incision designs, the choice of material, grafting technique, and donor site morbidity. Stabilizing particulated grafts for defined defects-that is, via meshes or shells-might allow significant horizontal and vertical augmentation; the alternatives are onlay and inlay techniques. More significant defects might require extra orally harvested autologous bone blocks. The anterior iliac crest is often used for nonvascularized augmentation, whereas more extensive defects often require microvascular reconstruction. In those cases, the free fibula flap has become the standard of care. The development of alternatives is still ongoing (i.e., alloplastic reconstruction, zygomatic implants, obturators, distraction osteogenesis). Especially for these complex procedures, three-dimensional planning tools enable facilitated planning and a surgical workflow.

Clinical importance of tumor rupture in gastrointestinal stromal tumor.

Risk factors of gastrointestinal stromal tumors (GISTs) include tumor size, location, mitosis, and tumor rupture. Although the first three are commonly recognized as independent prognostic factors, tumor rupture is not a consistent finding. Indeed, tumor rupture may be subjectively diagnosed and is rarely observed. Moreover, the criteria used for diagnosis differ among oncologists, which may result in inconsistent outcomes. Based on these conditions, a universal definition of tumor rupture was proposed in 2019 and consists of six scenarios: tumor fracture, blood-stained ascites, gastrointestinal perforation at the tumor site, histologically proven invasion, piecemeal resection, and open incisional biopsy. Although the definition is considered appropriate for selection of GISTs with worse prognostic outcomes, each scenario lacks a high level of evidence and there is yet no consensus for some, including histological invasion and incisional biopsy. It may be, however, important to have common criteria for clinical decision-making, which may facilitate reliability, external validity, and comparability of clinical studies in rare GISTs. After the definition, several retrospective reports indicated that even with adjuvant therapy, tumor rupture was associated with high recurrence rates and poor prognostic outcomes. The prognosis of patients with ruptured GISTs is improved by 5-year adjuvant therapy compared with 3-year therapy. Nevertheless, the universal definition requires further evidence, and prospective clinical studies based on the definition are warranted.

Physician treatment preferences for relapsed/refractory multiple myeloma: a discrete choice experiment.

Aim: This study aimed to assess physician preferences for later lines (third to fifth) of therapy in patients with relapsed/refractory multiple myeloma (RRMM) in the USA. Materials & methods: Factors relevant to physicians' treatment preferences for RRMM were identified from a literature search and refined in a qualitative phase. Preferences were quantitatively assessed using a discrete choice experiment. Physicians (n=227) made choices regarding treatment scenarios for RRMM. Results: Efficacy had the highest mean relative importance, with overall survival valued as most important when making treatment decisions for patients with RRMM. Reduced incidences of keratopathy and thrombocytopenia had similar relative importance in later-line treatment. Conclusion: Greater understanding of physicians' criteria for clinical decision-making may help inform wider adoption of new treatments.

The comparison of PECARN, CATCH, AND CHALICE criteria in children under the age of 18 years with minor head trauma in emergency department

Introduction: Minor head traumas constitute a significant part of childhood injuries. The incidence of intracranial pathologies in children with minor head trauma varies in the range of 3%–5%, but it is higher among younger infants. The criteria of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events are the most frequently accepted clinical decision-making criteria that were developed for selective computerized tomography requests. This study was conducted to assess the diagnostic performances of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria in Turkish society, determine their validity, and find the most suitable algorithm for cranial imaging in children with minor head trauma. Methods: This study retrospectively examined the data of patients under the age of 18 years who were admitted to the Emergency Medicine Department of Uludağ University Medical Faculty due to minor head trauma; 530 patients were included as they complied with the criteria. The exclusion criteria were being any trauma patients above the age of 18 years, Glasgow Coma Scale <13, pregnant patients, hemorrhagic diathesis, using anticoagulants, patients with penetrant trauma, patients with priorly known brain tumor, and patients with neurological diseases. The patients were divided into group based on the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events Criteria. Results: Among all patients, 37.40% were female and 62.60% were male. Abnormal computed tomography findings such as epidural bleeding, subdural bleeding, and skull fractures were detected in 44 of the patients. The sensitivity of the Pediatric Emergency Care Applied Research Network criteria was 72.4%, the specificity was 54.5%, the sensitivity of the Canadian Assessment of Tomography for Childhood Head Injury criteria was 57.8%, the specificity was 50%, the sensitivity of the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria was 87.7%, and the specificity was 20%. Conclusion: Given the populations to which the rules apply, it is understood that the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria is more determinative in detecting pathological computed tomography outcomes compared to Pediatric Emergency Care Applied Research Network and Canadian Assessment of Tomography for Childhood Head Injury.

The Febrile Infant: Where Art Meets Science to Prevent Harm.

1. Mobeen H. Rathore, MD, CPE* 1. *Editorial Board Member, Pediatrics in Review > With a nod (tongue in cheek) to the author’s previously published title (1) > One consistent thought continues to hold true when it comes to assessing the febrile infant. Be suspicious. > > —JZ, HDA Perhaps Dr Arnold Smith put it most eloquently: “Sorting out the child at risk, from those with illness that is not a threat to their health, is a fundamental goal of pediatrics” (Fig 1). (2) What Dr Smith wrote 40 years ago is true even today. Fever continues to be one of the most common ailments in children. Although fever is a friend of the patient, infection is a foe. Identifying the foe is a complicated task for the evaluating physician. This is even more challenging in infants and especially neonates because of less-than-optimal history, mostly unreliable examination, and more specific signs of infection in the neonates often appearing later in the disease course. Even a thorough laboratory evaluation is not always helpful. Ultimately it is the selection of optimum broad spectrum empirical antibiotic drug therapy that is really the most important decision to protect neonates from the serious morbidity and mortality of neonatal sepsis. Fortunately, most infections in children, including in neonates, are viral and self-limited, causing no serious morbidity. Unfortunately, rarely, bacterial infections can be serious and sometimes life-threatening. Herein lies the challenge even for the most experienced and knowledgeable …

Perioperative factors associated with short- and long-term outcomes after tricuspid valve replacement.

Appropriate patient selection for tricuspid valve replacement (TVR) is crucial for optimal outcomes, but the objective criteria for clinical decision-making remain poorly defined. This study aimed to investigate the factors associated with short- and long-term survival and morbidity. This was a retrospective study of 202 consecutive patients who underwent TVR at the Beijing Anzhen Hospital over a 21-year period (from November 1993 to March 2014). Data were extracted from the hospital's computerized database with additional information obtained through mail or telephone interview. The overall 30-day mortality was 16%. Multivariate analysis showed that the dose of frusemide [odds ratio (OR) = 1.021, 95% confidence interval (95% CI): 1.003-1.038; P = 0.018] was an independent predictor of short-term death after TVR. The dose of frusemide (OR = 1.024, 95% CI: 1.008-1.040; P = 0.002), previous operation (OR = 4.681, 95% CI: 1.938-11.310; P = 0.01) and cardiopulmonary bypass time (OR = 1.013, 95% CI: 1.007-1.020; P < 0.001) were independently associated with the low output syndrome (LOS). After 8.2 ± 5.6 (range 1-22) years of follow-up, the survival rates were 75 ± 3, 71 ± 4 and 63 ± 5% at 5, 10 and 15 years, respectively. Preoperative hypoproteinaemia and postoperative LOS were independently associated with long-term mortality. This study identified a number of factors that were independently associated with short-term mortality, short-term LOS and long-term mortality of patients after TVR.

Implementation of standardization in clinical practice: not always an easy task

As soon as a new reference measurement system is adopted, clinical validation of correctly calibrated commercial methods should take place. Tracing back the calibration of routine assays to a reference system can actually modify the relation of analyte results to existing reference intervals and decision limits and this may invalidate some of the clinical decision-making criteria currently used. To maintain the accumulated clinical experience, the quantitative relationship to the previous calibration system should be established and, if necessary, the clinical decision-making criteria should be adjusted accordingly. The implementation of standardization should take place in a concerted action of laboratorians, manufacturers, external quality assessment scheme organizers and clinicians. Dedicated meetings with manufacturers should be organized to discuss the process of assay recalibration and studies should be performed to obtain convincing evidence that the standardization works, improving result comparability. Another important issue relates to the surveillance of the performance of standardized assays through the organization of appropriate analytical internal and external quality controls. Last but not least, uncertainty of measurement that fits for this purpose must be defined across the entire traceability chain, starting with the available reference materials, extending through the manufacturers and their processes for assignment of calibrator values and ultimately to the final result reported to clinicians by laboratories.

Proximal gastric cancer: advances of laparoscopic surgery

Although the overall incidence of gastric cancer is decreasing, gastric cancer still remains the fourth most common cancer worldwide. The decrease in the incidence rate varies considerably depending on the geographical area. For example, gastric cancer is continuously the most common cancer type in Asian countries such as Japan, Korea, and China, with a slow and slight drop in the prevalence of the disease in these countries. There has been a greater decrease in the incidence curve over the last few decades in the USA and northwest Europe, but the prevalence of proximal and gastroesophageal junction cancer in these areas is increasing. Therefore, there is interest in how to manage patients with upper-third stomach cancer to improve oncological and quality-of-life (QOL) outcomes not only in the Eastern but also in the Western world. The Aihara et al. [1] report in the September issue of Surgical Endoscopy provides useful information for the laparoscopic surgical treatment of patients with proximal gastric cancer. The authors describe a technique of laparoscopy-assisted proximal gastrectomy (LAPG) and gastric tube reconstruction using a miniloop retractor (MLR). The feasibility and safety of this technique was evaluated in 44 patients with early-stage upper gastric carcinoma. Five surgical ports were inserted into the abdomen and the stomach was lifted to the abdominal wall side with a MLR. Reconstruction with a gastric tube (20 cm long, 3 cm wide) using a circular stapler was performed through a small incision, through which the specimen was removed. The mean operating time was 202 min. There were no serious complications no deaths, and no conversions to open surgery. The authors concluded that this technique of LAPG and gastric tube reconstruction using MLR is feasible and safe for the treatment of proximal early gastric cancer. The data provided by Aihara et al. [1] support the safety of their technique, which is technically more complicated than laparoscopy-assisted distal gastrectomy (LADG). The incidence of early gastric cancer (EGC) in Japan and Korea is high and approximately 50% of cases are diagnosed at this early stage through established nationwide endoscopic screening. These high EGC rates have led to the development and validation of minimally invasive approaches, including endoscopic submucosal dissection (ESD) and laparoscopic surgery in these countries. Criteria for clinical decision-making on ESD, laparoscopic gastrectomy, or open surgery have been defined by Japanese scientific associations. There is now an explosion in laparoscopic surgery for the treatment of gastric cancer in Asian countries and also an increase in the use of this minimally invasive approach in some specialized centers in the West [2]. Based on strong evidence of the superiority of laparoscopic versus open surgery with respect to quality of life for colorectal cancer patients [3] and accumulating evidence, although still incomplete, for early gastric cancer patients [4–6], the technique of laparoscopic gastrectomy has evolved rapidly. Now, the evolution includes totally intracorporeal laparoscopic distal, proximal, or total gastrectomy with standardized extended D2 lymphadenectomy, and indications for its use have been expanded to include patients with advanced resectable stage II and stage III disease [2]. Survival benefits of D2 surgery [7] are now being confirmed by the long-term 15 year survival results of a Dutch trial [8]. This assessment of D2 surgery gains in open surgery makes this standardized lymphadenectomy an C. Batsis (&) Department of Surgery, School of Medicine, University of Ioannina, 451 10 Ioannina, TK, Greece e-mail: chbatsis@hotmail.com

INTELLECTUAL REASONING AND CLINICAL DECISION-MAKING CRITERIA OF CRITICAL CARE NURSES: A QUALITATIVE STUDY

Background and aim Nurses make important clinical decisions with a great impact on patient care and their professional performance. Although decision-making is a basic and essential concept of nursing, limited understanding exists regarding the quality of clinical decision-making of critical care nurses and its effective factors. The purpose of this qualitative descriptive study was to explore intellectual reasoning and clinical decision-making criteria of critical care nurses. Material and methods 14 nurses in 4 teaching hospitals affiliated with Tehran University of Medical Sciences participated in the study. Data were collected by in-depth semi-structured interviews. Content analysis was used to analyze the data. The interviews were transcribed verbatim and analyzed concurrently with data collection. Findings In general, 6 main themes emerged.3 related to intellectual reasoning included intuition, recognition of similar situations and hypothesis testing and the other 3concerning criteria ofdecision-making were risk-benefit level, organizational requirements and complementary sources of information. Conclusion The findings provide a deep understanding of critical care nurses’ experiences regarding intellectual reasoning and clinical decision-making criteria. This can be influential in addition to facilitating more efficient decision-makings on improving the outcomes of independent as well as collaborative nursing interventions. Keywords: Clinical decision-making, Nurses, Critical care, Content analysis. * Corresponding Author: Farhad, Ramezanibadr. Dept. of Medical-Surgical Nursing, College of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, Iran. E-mail: ramazanibadr@zums.ac.ir

Would it be possible to develop a set of Ottawa wrist rules to facilitate clinical decision making?

Purpose To analyze the possibility of creating clinical decision- making rules to facilitate the assessment of conventional x-rays in acute wrist trauma. Materials and methods This is a prospective observational study. Data was collected on patients treated at the Emergency Department of our hospital further to sustaining acute wrist trauma. 179 patients were included in the study. 46 clinical interview and physical examination variables were used for each patient. Inter-examiner concordance was analyzed for the variables, as well as their statistical association with positive wrist radiology. Data was subsequently analyzed by means of multivariate analysis. Results All 57 patients with positive wrist x-ray images presented with at least one of these characteristics: age equal to or higher than 35, edema of the dorsum of the wrist; limited supination or active radial deviation; and pain or instability on the distal radioulnar drawer test. This clinical decision-making rule is 100% sensitive and 37.7% specific to detect patients with positive wrist x-ray images further to acute trauma. Its use in the sample under study would have reduced the number of x-ray requests by 15.6%. Conclusions A broader study should be undertaken in order to assess the acceptance of a series of clinical decisionmaking criteria for the carrying out of radiographs further to acute wrist trauma.

The predictive value of ultrasound findings in the management of thyroid nodules

Thyroid nodules are a common medical problem, but whether fine-needle aspiration cytology (FNAC) is mandated for smaller non-palpable nodules, is controversial. To evaluate whether ultrasonographic features of thyroid nodules are associated with histological malignancy, and to identify useful criteria for clinical decision-making. Prospective observational study. From January 1991 to September 2004, 5198 patients were referred to our hospital for ultrasound evaluation of thyroid nodules. Overall, 7455 nodules (diameters from 6 to 100 mm) were examined; 2865 (38.4%) were <10 mm in diameter. All patients with suspicious or malignant cytology underwent surgery. Of the 349 nodules undergoing surgery, 284 were malignant. The prevalence of cancer was slightly higher in nodules>or=10 mm in diameter vs. those<10 mm (5.5% vs. 3.0%, p<0.01). However, histological type and local aggressiveness were largely independent of nodule size. Microcalcifications (72.2% vs. 28.7%; p<0.001; OR 6.4, 95%CI 4.9-8.4), blurred margins (52.8% vs. 18.8%; p<0.001; OR 4.8, 95%CI 3.8-6.1), solid hypoechoic appearance (80.6% vs. 52.4%; p<0.001; OR 3.8, 95%CI 2.8-5.1), size>or=10 mm (77.4% vs. 64.9%; p<0.001; OR 1.9, 95%CI 1.4-2.5) and intranodular vascular pattern type 2 (61.6% vs. 49.7%; p<0.001; OR 1.6, 95%CI 1.2-2.0) were all significantly more frequent in malignant than in benign nodules. These associations were similar when large and small nodules were analysed separately. No single parameter, including nodule size, satisfactorily identifies a subset of patients to be electively investigated by FNAC, although several may be useful in this regard.

Critical pathways for the management of preeclampsia and severe preeclampsia in institutionalised health care settings.

BackgroundPreeclampsia is a complex disease in which several providers should interact continuously and in a coordinated manner to provide proper health care. However, standardizing criteria to treat patients with preeclampsia is problematical and severe flaws have been observed in the management of the disease. This paper describes a set of critical pathways (CPs) designed to provide uniform criteria for clinical decision-making at different levels of care of pregnant patients with preeclampsia or severe preeclampsia.MethodsClinicians and researchers from different countries participated in the construction of the CPs. The CPs were developed using the following steps: a) Definition of the conceptual framework; b) Identification of potential users: primary care physicians and maternal and child health nurses in ambulatory settings; ob/gyn and intensive care physicians in secondary and tertiary care levels. c) Structural development.ResultsThe CPs address the following care processes: 1. Screening for preeclampsia, risk assessment and classification according to the level of risk. 2. Management of preeclampsia at primary care clinics. 3. Evaluation and management of preeclampsia at secondary and tertiary care hospitals: 4. Criteria for clinical decision-making between conservative management and expedited delivery of patients with severe preeclampsia.ConclusionSince preeclampsia continues to be one of the primary causes of maternal deaths and morbidity worldwide, the expected impact of these CPs is the contribution to improving health care quality in both developed and developing countries. The CPs are designed to be applied in a complex health care system, where different physicians and health providers at different levels of care should interact continuously and in a coordinated manner to provide care to all preeclamptic women. Although the CPs were developed using evidence-based criteria, they could require careful evaluation and remodelling according to each system's demands. Additionally, the CPs need to be tested in large-scale, multi-level studies in order to thoroughly examine and evaluate their efficacy and effectiveness.

The painful hip: evaluation of criteria for clinical decision-making.

Children with a painful hip present a diagnostic challenge since clinical differentiation between septic arthritis, transient synovitis and Perthes disease may be difficult. Septic arthritis, a potentially life-threatening and debilitating medical emergency, requires early recognition for successful treatment, while transient synovitis and Perthes disease may be managed conservatively. An "ideal" single test for discrimination between these conditions is currently not available. We assessed the value of clinical examination and simple laboratory tests together with radiography and hip ultrasound in differentiating septic arthritis from transient synovitis and Perthes disease by analyzing the records of 89 children treated at our institution for hip pain. Ultrasound, radiographs, laboratory, clinical, and follow-up data were available for all the children. Diagnoses were made according to established criteria. Transient synovitis was present in 64 patients, septic arthritis in 8 (of whom 2 had additional osteomyelitis), and Perthes disease in 4. All children with septic arthritis had hip effusion shown by ultrasound and at least two of the following criteria: fever, elevation of erythrocyte sedimentation rate (ESR) and of C-reactive protein (CRP). None of the children without effusion on ultrasound or who lacked two or all criteria had septic arthritis. Radiographs had no significant impact on the decision-making in primary evaluation of acute hip pain. We conclude that investigation of painful hips in children, based on hip ultrasound, body temperature, ESR and CRP, may allow cases for hip joint aspiration to be selected efficiently and may reduce the number of radiographs and hospital admissions.