Clinical Practice Improvement Research Articles

Improvements in Clinical Laboratory Techniques, Technologies, and Practices with a Focus on the Equipment and Personnel: A Consolidated Review

Improvements in Clinical Laboratory Techniques, Technologies, and Practices with a Focus on the Equipment and Personnel: A Consolidated Review

Applying Functional Imaging to Clinical Practice: Are We Making Progress Toward Its Promise?

Applying Functional Imaging to Clinical Practice: Are We Making Progress Toward Its Promise?

Nomograms for predicting overall survival and cancer-specific survival of patients with stage IV renal cell carcinoma: A SEER population-based study

<sec><strong>Background</strong> The purpose of this study was to explore independent favorable prognostic factors for predicting 1-, 3-, and 5-year overall survival (OS) and cancer-specific survival (CSS) in patients with stage Ⅳ cell renal cell carcinoma (RCC) by constructing nomograms. </sec><sec><strong>Methods</strong> A total of 2636 patients diagnosed with stage Ⅳ RCC from 2010 to 2015 were enrolled in the surveillance, epidemiology, and end results database. Multivariate Cox hazard regression and competing risk analysis were used for searching prognosis factors in the cohort. The nomograms were constructed for predicting 1-, 3-, and 5-year of OS and CSS. Concordance index (C-index) and the calibration curves were used to evaluate the discrimination and accuracy of the nomograms. </sec><sec><strong>Results</strong> Age, nephrectomy, histology, N stage, and brain/liver/lung metastasis were identified as independent favorable prognostic factors in OS and CSS via univariate and multivariate analyses. Other variables were further selected by clinical practice and net reclassification improvement (NRI). Finally, age, nephrectomy, histology, grade, tumor size, T stage, N stage, and bone/brain/liver/lung metastasis were chosen to construct nomograms. The C-index of the OS and CSS in nomograms were 0.697 (95% confidence interval (CI), 0.683–0.711) and 0.655 (95% CI, 0.639–0.671), respectively. The calibration curves revealed high consistency between the nomograms prediction and actual observation. </sec><sec><strong>Conclusions</strong> The nomograms may help clinicians to conveniently predict the survival of RCC patients with stage Ⅳ and provide guidance in choosing the suitable management. </sec>

Effective handovers on escalation of care for the deteriorating patient.

Evidence suggests that improvements in clinical practice are required to ensure that deteriorating patients are rapidly identified and assessed in a systematic manner. The important step of escalating care involves a detailed handover to the most appropriate colleague so that interventions can be put in place to reverse or optimise the patient's condition. However, multiple issues can hinder this handover process, including a lack of confidence among nurses and suboptimal team dynamics or cultures. Using structured communication tools such as situation, background, assessment, recommendation (SBAR) can assist nurses in delivering a handover that results in the desired outcome. This article explains the steps involved in identifying, assessing and escalating the care of deteriorating patients, and describes the components of an effective handover.

Design and Development of a Web-Based Prospective Nationwide Registry for Ocular Inflammatory Diseases: UVEITE.PT – The Portuguese Ocular Inflammation Registry

ABSTRACT Uveitis is a heterogeneous collection of infrequent diseases, which poses significant challenges to cost-effective research in the field. Medical registries are being increasingly recognized as crucial tools to provide high-quality data, thus enabling prospective clinical research. This paper describes the design and technical structure development of an innovative countrywide electronic medical record for uveitis, Uveite.pt, and gives an overview of the cohort registered since its foundation, March 2020. Uveite.pt is an electronic medical record platform developed by the Portuguese Ocular Inflammation Group (POIG), a scientific committee of the Portuguese Ophthalmology Society. This is a nationwide customized web-based platform for uveitis patients useful for both clinical practice and real-world-based research, working as a central repository and reporting tool for uveitis. This paper describes the technical principles, the design and the development of a web-based interoperable registry for uveitis in Portugal and provides an overview of more than 400 patients registered in the first 18 months since inception. In infrequent diseases, the existence of registries enables to gather evidence and increase research possibilities to clinicians. The adoption of this platform enables standardization and improvement of clinical practice in uveitis. It is useful to apprehend the repercussion of medical and surgical treatments in uveitis and scleritis, supporting clinicians in the strict monitoring of drug adverse reactions and surgical outcomes.

Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial

BackgroundCervical spondylotic myelopathy (CSM) is the predominant cause of spinal cord dysfunction in the elderly. The patients are often frail and susceptible to complications. Posterior surgical techniques involving non-fusion are complicated by postlaminectomy kyphosis and instrumented fusion techniques by distal junction kyphosis, pseudarthrosis, or implant failure. The optimal surgical approach is still a matter of controversy.Since anterior and posterior fusion techniques have been compared without presenting any superiority, the objective of this study is to compare stand-alone laminectomy with laminectomy and fusion to determine which treatment has the lowest frequency of reoperations.MethodsThis is a multicenter randomized, controlled, parallel-group non-inferiority trial. A total of 300 adult patients are allocated in a ratio of 1:1. The primary endpoint is reoperation for any reason at 5 years of follow-up. Sample size and power calculation were performed by estimating the reoperation rate after laminectomy to 3.5% and after laminectomy with fusion to 7.4% based on the data from the Swedish spine registry (Swespine) on patients with CSM. Secondary outcomes are the patient-derived Japanese Orthopaedic Association (P-mJOA) score, Neck Disability Index (NDI), European Quality of Life Five Dimensions (EQ-5D), Numeric Rating Scale (NRS) for neck and arm pain, Hospital Anxiety and Depression Scale (HADS), development of kyphosis measured as the cervical sagittal vertical axis (cSVA), and death. Clinical and radiological follow-up is performed at 3, 12, 24, and 60 months after surgery. The main inclusion criterium is 1–4 levels of CSM in the subaxial spine, C3–C7. The REDcap software will be used for safe data management. Data will be analyzed according to the modified intention to treat (mITT) population, defined as randomized patients who are still alive without having emigrated or left the study after 2 and 5 years.DiscussionThis will be the first randomized controlled trial comparing two of the most common surgical treatments for CSM: the posterior muscle-preserving selective laminectomy and posterior laminectomy with instrumented fusion. The results of the myelopathy randomized controlled (MyRanC) study will provide surgical treatment recommendations for CSM. This may result in improvements in surgical treatment and clinical practice regarding CSM.Trial registrationClinicalTrials.govNCT04936074. Registered on 23 June 2021

Improvements in Clinical Laboratory Techniques, Technologies, and Practices with A Focus on The Equipment and Personnel: A Consolidated Review

Improvements in Clinical Laboratory Techniques, Technologies, and Practices with A Focus on The Equipment and Personnel: A Consolidated Review

Development and Validation of a Photonumeric Scale for Evaluation of Lip Fullness.

The shape, proportion, and fullness of one's lips are associated with overall facial beauty and attractiveness. Lip augmentation, due to personal preference or to reverse natural aging, has become a standard clinical procedure to improve lip volume or proportion. Several options are available to redefine the lips. To objectively evaluate treatment-related improvements in clinical practice and research, a validated photonumeric scale is needed. To present scale-development methods for the Merz Lip Fullness Assessment Scale (MLFAS) and establish its reliability. A 5-point photonumeric scale was developed to objectively assess loss of lip volume using male and female subjects of various ages and skin types. To establish intra- and interrater reliability, 8 board-certified dermatologists and plastic surgeons evaluated 64 subjects live in 2 sessions, 2 weeks apart. The weighted kappa for intra- and interrater agreement were &ge; 0.6 in all cases. Intrarater agreement between the 2 rating sessions was nearly perfect (median weighted kappa = 0.911 and 0.930 for the upper lip and lower lip, respectively). Substantial interrater agreement between each rater pair was also demonstrated for both rating sessions, and ratings of upper and lower lip fullness showed comparable reliability. The MLFAS is a validated and reliable photonumeric scale for rating loss in lip volume. The scale maintains its reliability with reproducible results across a diverse group of males and females of various ages and Fitzpatrick skin types. J Drugs Dermatol. 2023;22(3): doi:10.36849/JDD.7309.

Quality improvements in radiation oncology clinical trials.

Clinical trials have become the primary mechanism to validate process improvements in oncology clinical practice. Over the past two decades there have been considerable process improvements in the practice of radiation oncology within the structure of a modern department using advanced technology for patient care. Treatment planning is accomplished with volume definition including fusion of multiple series of diagnostic images into volumetric planning studies to optimize the definition of tumor and define the relationship of tumor to normal tissue. Daily treatment is validated by multiple tools of image guidance. Computer planning has been optimized and supported by the increasing use of artificial intelligence in treatment planning. Informatics technology has improved, and departments have become geographically transparent integrated through informatics bridges creating an economy of scale for the planning and execution of advanced technology radiation therapy. This serves to provide consistency in department habits and improve quality of patient care. Improvements in normal tissue sparing have further improved tolerance of treatment and allowed radiation oncologists to increase both daily and total dose to target. Radiation oncologists need to define a priori dose volume constraints to normal tissue as well as define how image guidance will be applied to each radiation treatment. These process improvements have enhanced the utility of radiation therapy in patient care and have made radiation therapy an attractive option for care in multiple primary disease settings. In this chapter we review how these changes have been applied to clinical practice and incorporated into clinical trials. We will discuss how the changes in clinical practice have improved the quality of clinical trials in radiation therapy. We will also identify what gaps remain and need to be addressed to offer further improvements in radiation oncology clinical trials and patient care.

Functional and regulatory impact of chimeric RNAs in human normal and cancer cells.

Fusions of two genes can lead to the generation of chimeric RNAs, which may have a distinct functional role from their original molecules. Chimeric RNAs could encode novel functional proteins or serve as novel long noncoding RNAs (lncRNAs). The appearance of chimeric RNAs in a cell could help to generate new functionality and phenotypic diversity that might facilitate this cell to survive against new environmental stress. Several recent studies have demonstrated the functional roles of various chimeric RNAs in cancer progression and are considered as biomarkers for cancer diagnosis and sometimes even drug targets. Further, the growing evidence demonstrated the potential functional association of chimeric RNAs with cancer heterogeneity and drug resistance cancer evolution. Recent studies highlighted that chimeric RNAs also have functional potentiality in normal physiological processes. Several functionally potential chimeric RNAs were discovered in human cancer and normal cells in the last two decades. This could indicate that chimeric RNAs are the hidden layer of the human transcriptome that should be explored from the functional insights to better understand the functional evolution of the genome and disease development that could facilitate clinical practice improvements. This review summarizes the current knowledge of chimeric RNAs and highlights their functional, regulatory, and evolutionary impact on different cancers and normal physiological processes. Further, we will discuss the potential functional roles of a recently discovered novel class of chimeric RNAs named sense-antisense/cross-strand chimeric RNAs generated by the fusion of the bi-directional transcripts of the same gene. This article is categorized under: Regulatory RNAs/RNAi/Riboswitches > Regulatory RNAs.

Development and Validation of a Photonumeric Scale for Evaluation of Jawline Contour.

A naturally aged face is often characterized by a noticeable lack of jawline contour and decreased volume in the lower region. Several options are available to redefine the jawline. To objectively evaluate treatment-related improvements in clinical practice and research, a validated photonumeric scale is needed. To present scale-development methods for the Merz Jawline Assessment Scale and establish its reliability. A 5-point photonumeric scale was developed to objectively assess jawline volume loss and contour disruption using male and female subjects of various ages and skin types. Seven board-certified dermatologists and plastic surgeons evaluated 90 subjects live in 2 sessions, 3 weeks apart to establish intra- and interrater reliability. The weighted kappa for intra- and interrater agreement were &ge; 0.7 in all cases. Intrarater agreement between the 2 rating sessions was nearly perfect (median weighted kappa = 0.908). Substantial interrater agreement between each rater pair was also demonstrated for both rating sessions. The Merz Jawline Assessment Scale is a validated and reliable photonumeric scale for rating loss of jawline volume and contour. The scale maintains its validity and reliability with reproducible results across a diverse group of males and females of various ages and Fitzpatrick skin types. J Drugs Dermatol. 2023;22(2):203-209. doi:10.36849/JDD.7193.

Discussion Guide for the van Nieuw Amerongen Article.

Discussion Guide for the van Nieuw Amerongen Article.

Prevalence of risk factors for primary postpartum hemorrhage in a university hospital.

to identify the risk factors associated with primary postpartum hemorrhage in a university hospital. a cross-sectional study was conducted with 277 postpartum women who received care during childbirth or cesarean section between June and August 2020. Data were collected using a pre-structured questionnaire administered 24 hours after delivery. Poisson Regression was employed to analyze the factors associated with postpartum hemorrhage. postpartum hemorrhage was observed in 30% of the study sample. Shock Index and uterine distension were found to be statistically associated with postpartum hemorrhage. Postpartum women with a Shock Index ≥ 0.9 had a 61% higher prevalence of postpartum hemorrhage (PR=1.61, 95% CI: 1.07 - 2.43), while those with uterine distension had a 134% higher prevalence (PR=2.34, 95% CI: 1.63 - 3.36). recognizing these factors contributes to improvements in clinical practice, as they enable the prediction of their occurrence and call for appropriate management, thereby preventing unfavorable outcomes.

The Suicidal Patient in the Emergency Department Team-Based Learning Activity.

Emergency medicine resident physicians, (PGY1-4), medical students rotating in the emergency department. Emergency physicians have a duty to recognize and provide care for patients who attempt to harm themselves or commit suicide. Mental health-related chief complaints account for 12.5% of emergency department (ED) visits.1 Additionally, patients with depressive symptoms who are discharged from the ED are at the highest risk for suicidal thoughts and behaviors.1 Therefore, evaluating and screening for suicide and determining appropriate dispositions for this patient population is extremely important. This team-based learning (TBL) activity will help prepare residents and medical students to evaluate, recognize, and disposition this at-risk patient population. By the end of the session, participants will be able to: 1) describe risk factors for suicide; 2) summarize the emergency physician's role in assessing patients with psychiatric emergencies; 3) assess a patient using a mental status evaluation; 4) identify the criteria for involuntary psychiatric hold placement; 5) develop a safe discharge plan for patients experiencing depression; and 6) Formulate a plan for evaluating a suicidal patient who is acutely intoxicated. This team-based learning activity is a classic TBL that includes learner responsible content (LRC), an individual readiness assessment test (iRAT), a multiple choice group readiness assessment test (gRAT) with immediate feedback assessment technique (IF/AT), and a group application exercise (GAE). A post-TBL survey was provided to each participant. A Likert scale was used for the survey questions to assess the relevance of the session to emergency medicine practice, learner perception of knowledge gained, learner perception of improvement of clinical practice, session engagement, and session delivery. The post-activity evaluation had a response rate of 33% (11/33). Overall, all the participants "strongly agreed" (Likert 5/5) or "agreed" (Likert 4/5) that the session improved their knowledge of caring for the suicidal patient in the ED with an average score of 4.6/5. All participants "strongly agreed" (Likert 5/5) or "agreed" (Likert 4/5) that the material presented was relevant to their clinical practice in the ED for an average score of 4.6/5. Constructive feedback included requesting learner responsible content (LRC) be sent earlier than one week prior to the activity. Depression and suicidal ideation are common ED complaints. However, it can be difficult to evaluate these patients and select an appropriate disposition because their symptoms can range from benign to life-threatening. The team-based learning (TBL) session allows for discussion of the complexities of the depressed and suicidal patient. Learners found this TBL to be beneficial in providing a diagnostic pathway and treatment algorithm to manage these complex, high-risk patients. Suicide, depression, substance abuse, disposition, team-based learning.

Children and adolescents' mental health during the COVID-19 pandemic: A qualitative study of their experiences.

Public health measures implemented in response to the COVID-19 pandemic severely disrupted children and adolescents' (C&A) lives, affecting their sense of structure, predictability, and security. To examine C&A' experiences during the COVID-19 pandemic to better understand how this context and its associated public health measures affected them and their mental health, and to identify helpful coping strategies. The study was guided by a participatory hermeneutic framework. Semistructured interviews were conducted with 25C&A aged 6-17 years during the first and second pandemic waves. Participants' interviews were analyzed following a narrative synthesis approach, through which C&A' experiences were contrasted and contextualized to highlight relevant themes. Participants described a distinct pattern related to their mental health as the pandemic unfolded, which followed the severity of the pandemic in the province. Negative repercussions on their mental health were linked to the loss of social activities, imposed public health measures, transition to online learning, and challenges with family relationships. Certain youth shared positive societal and moral reflections triggered by the pandemic context. Coping strategies reported include: having a variety of hobbies; expressing their emotions; and accessing financial and material resources. This study highlights the importance of supporting C&A' mental health during crisis situations such as a pandemic. Their perspectives are vital for clinical practice and policy improvement, particularly to find means for social engagement while maintaining safety.

The role of the microbiota-gut-brain axis in long-term neurodegenerative processes following traumatic brain injury.

Traumatic brain injury (TBI) can be a devastating and debilitating disease to endure. Due to improvements in clinical practice, declining mortality rates have led to research into the long-term consequences of TBI. For example, the incidence and severity of TBI have been associated with an increased susceptibility of developing neurodegenerative disorders, such as Parkinson's or Alzheimer's disease. However, the mechanisms linking this alarming association are yet to be fully understood. Recently, there has been a groundswell of evidence implicating the microbiota-gut-brain axis in the pathogenesis of these diseases. Interestingly, survivors of TBI often report gastrointestinal complaints and animal studies have demonstrated gastrointestinal dysfunction and dysbiosis following injury. Autonomic dysregulation and chronic inflammation appear to be the main driver of these pathologies. Consequently, this review will explore the potential role of the microbiota-gut-brain axis in the development of neurodegenerative diseases following TBI.

An evidence-based change management model to guide NICHE implementation efforts

Changing practice is complex and multifaceted. I discuss an evidence-based change management model that can be applied to guide clinical practice improvement projects. I use NICHE as a case example. The overall success of any change initiatives relies on creating and following an action plan to address the “what of change” and the “how of change”. The “what of change” focuses on developing tailored interventions aligned with each nursing unit or service line strengths and opportunities to improve nursing care for older adults by implementing the four components of the NICHE practice model. The “how of change” focuses on the activities to prepare the environment to implement the NICHE practice model. Activities to manage the change process include how to effectively communicate a vision for change; mobilize managers, clinical leaders, and front-line staff to support the change in nursing practice; and tracking progress towards meeting clinical improvement goals over time.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline.

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality. To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia. A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia. The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Development and Validation of a Photonumeric Scale for Evaluation of Infraorbital Hollowing.

The infraorbital hollow is characterized by a sunken hollowing appearance of the junction between the lower eyelid and the cheek. Dermal fillers provide a suitable option to reduce the appearance of infraorbital hollowing. To objectively evaluate treatmentrelated improvements in clinical practice and research, a validated photonumeric scale is needed. To present the scale development methods for the Merz Infraorbital Hollow Assessment Scale and establish its reliability and clinical relevance. A 5-point photonumeric scale was developed to objectively assess the infraorbital hollowing among subjects of varying sex, age, and skin type. Intra- and inter-rater reliability was evaluated using live assessments conducted 2 weeks apart. The clinical relevance of a 1-point difference in scale-severity grade was evaluated through side by-side comparisons of photographs with either same grade or a one-grade difference. The scale demonstrated excellent reliability when used by trained physicians and other healthcare practitioners. Intra-rater agreement between the 2 live-subject rating sessions was nearly perfect. Substantial inter-rater agreement between the raters from both live sessions was also demonstrated. The mean absolute difference (95% confidence interval) in scale ratings was 1.08 (1.02, 1.14) for "clinically different" pairs and was 0.34 (0.27, 0.41) for "clinically same" pairs, suggesting a 1-point difference is clinically relevant. The Merz Infraorbital Hollow Assessment Scale is a validated, reliable, and clinically relevant photonumeric scale for rating infraorbital hollowing. The scale maintains its validity and reliability with reproducible results across a diverse group of males and females of various ages and Fitzpatrick Skin Types. J Drugs Dermatol. 2023;22(1):74-81.doi:10.36849/JDD.7191.

Diagnosis Of Inflammatory Bowel Disease in Mildly Elevated Faecal Calprotectin: Observation From A Clinical Audit In District Hospital In The UK

Faecal Calprotectin (FC) is a marker to diagnose inflammatory bowel disease (IBD), that is ulcerative colitis &amp; Crohn’s disease. Identifying IBD from other gut related disorder is of prime importance in managing the condition. FCis cheap and non-invasive, it also helps in assessing the further need of any possible invasive procedure such as colonoscopy or imaging studies. The main objective of this observational study was to diagnose new IBD in mildly raised FC value (60ug/g-300ug/g). This study was done in a district-level hospital in the UK. During the study, we noticed that a large number of patients had numerous investigations including colonoscopy and MRI imaging, and only one patient was diagnosed with new IBD in mildly elevated FC. These findings were presented at gastroenterology audit meeting held at our hospital. For further improvement of clinical practice and to reduce number of invasive investigation, below recommendation can be followed.