Regular Clinical Practice Research Articles

How to Face COVID-19 in Ophthalmology Practice

Background: The novel coronavirus pneumonia has attracted considerable attention from the international community. With the spread of outbreaks around the world, the WHO characterized COVID-19 as a pandemic.
 Methods: Relevant studies in PubMed were searched from January 1, 2020 to April 12, 2020, using the following search strategy: (“novel coronavirus pneumonia” OR “severe acute respiratory syndrome coronavirus 2” OR “coronavirus disease 2019” OR “COVID-19” OR “novel coronavirus pneumonia”) AND (“ophthalmology” OR “ophthalmologist” OR “eye” OR “conjunctiva” OR “conjunctivitis” OR “corneal” OR “keratitis”).
 Results: SARS-CoV-2 can spread through aerosol and is detected in tears of patients with COVID-19 infection. Notably, some infected patients had conjunctivitis, and conjunctivitis was the first symptom in some patients later diagnosed to have COVID-19 infection. This would increase the risk for ophthalmologists through inpatient consultations or regular clinical practice. When dealing with seemingly regular ophthalmic patients, the vigilance of ophthalmologists and associated staff tends to be reduced.
 Conclusion: Ophthalmologists must continuously update their knowledge regarding COVID-19 and take effective measures to prevent COVID-19 transmission.

PDG74 AVAILABILITY OF FDA-APPROVED SURROGATE MARKERS IN REAL-WORLD DATA

Validated surrogate markers that predict patient-relevant clinical outcomes can support more efficient clinical trials and regulatory decisions. While real-world evidence is increasingly used in decision-making, the availability of validated surrogates in real-world data (RWD) sources is unclear. We reviewed FDA-approved surrogates and determined the extent to which surrogate marker results are measurable within a representative claims and electronic health records (EHR) source. We extracted surrogates that were the basis of FDA drug approvals for common therapeutic areas from the FDA’s surrogate endpoints table. Using Optum’s de-identified Integrated Claims-Clinical dataset, we evaluated the percent of patients with surrogate marker results (365 days follow-up) within indication-specific cohorts. Cohorts included prevalent and incident users of drugs for indications corresponding to each surrogate approval, as specified by the FDA. Among the 23 FDA-approved surrogate markers identified for 16 indications, 16 (70%) were laboratory tested molecular biomarkers (e.g. HbA1c, HIV-RNA), 5 (22%) required radiographic assessments (e.g. tumor progression, bone density), and 2 (9%) were physiological assessments (FEV1, blood pressure). Overall, 16 (70%) of 23 surrogate markers could be operationalized in the representative database. The percent of patients with surrogate results across indication-specific cohorts ranged from 4% (FEV1) to 86% (blood pressure). Molecular biomarkers were the most common surrogate type, due to cardiometabolic markers collected in regular clinical practice (LDL, triglycerides, HbA1c). Surrogates from unstructured sources (e.g. clinician notes) and endpoints requiring a sequence of assessments to measure changes over time were available in a subset of indication-specific cohorts with necessary data. This study demonstrates opportunities to use FDA-approved surrogates in RWD studies and monitoring of disease status in real-world settings. Further research is needed to develop and validate algorithms for extracting surrogate outcomes from structured and unstructured health data sources.

Effectiveness of a multifactorial intervention, consisting of self-management of antihypertensive medication, self-measurement of blood pressure, hypocaloric and low sodium diet, and physical exercise, in patients with uncontrolled hypertension taking 2 or more antihypertensive drugs: The MEDICHY study.

Introduction:High blood pressure is the leading modifiable risk factor for cardiovascular disease, and is associated with high morbidity and mortality and with significant health care costs for individuals and society. However, fewer than half of the patients with hypertension receiving pharmacological treatment have adequate blood pressure control. The main reasons for this are therapeutic inertia, lack of adherence to treatment, and unhealthy lifestyle (i.e., excess dietary fat and salt, sedentary lifestyle, and overweight). Cardiovascular risk and mortality are greater in hypertensive patients who are receiving treatment but have suboptimal control of blood pressure.Methods/Design:This is a multicentre, parallel, 2-arm, single-blind (outcome assessor), controled, cluster-randomized clinical trial. General practitioners and nurses will be randomly allocated to the intervention group (self-management of antihypertensive medication, self-measurement of blood pressure, hypocaloric and low sodium diet, and physical exercise) or the control group (regular clinical practice). A total of 424 patients in primary care centers who use 2 or more antihypertensive drugs and blood pressure of at least 130/80 during 24-hambulatory blood pressure monitoring will be recruited. The primary outcome is systolic blood pressure at 12 months. The secondary outcomes are blood pressure control (<140/90 mm Hg); quality of life (EuroQol 5D); direct health care costs; adherence to use of antihypertensive medication; and cardiovascular risk (REGICOR and SCORE scales).Discussion:This trial will be conducted in the primary care setting and will evaluate the impact of a multifactorial intervention consisting of self-management of blood pressure, antihypertensive medications, and lifestyle modifications (hypocaloric and low sodium diet and physical exercise).

A232 EFFICACY OF TOFACITINIB FOR THE TREATMENT OF MODERATE-TO-SEVERE ULCERATIVE COLITIS: REAL-WORLD DATA

Abstract Background A significant proportion of patients with moderate to severe ulcerative colitis (UC) do not respond to therapy, which includes thiopurines, glucocorticoids, and antagonists to tumour necrosis factor-α and integrin. Tofacitinib, a Janus Kinase inhibitor, has emerged as an efficacious and safe treatment for moderate to severe ulcerative colitis. However, it is not known if this efficacy translates into real-life effectiveness in a regular clinical practice. Aims We aimed to assess the rate of clinical response and clinical remission at 3 and 6 months after tofacitinib initiation. Secondary endpoints included rate of biomarker normalization, corticosteroids-free clinical remission and severe infections. Methods We conducted a multi-center retrospective observational study of adult patients with active UC started on tofacitinib from January 1, 2015 to October 1, 2019 at the McGill University Health Center and Hotel-Dieu de Lévis. A positive clinical response was defined as a decrease of ≥3 in the partial Mayo score. Clinical remission was defined as partial Mayo score of ≤2. Biomarker normalization was defined as fecal calprotectin ≤250ug/g. Severe infection was defined as an infection requiring hospitalization. Results During the study period, 40 patients with UC were started on tofacitinib. Amongst the patients, 85% (n=34) had failed ≥1 biologic and 50% (n=20) had failed ≥3 biologics. At the time of this preliminary analysis, 38 patients had undergone 3 months of treatment and 30 patients had undergone 6 months of treatment. At 3 months, a clinical response was seen in 89.5% of patients (n=34) and clinical remission occurred in 63.2% (n=24). At 6 months, clinical response occurred in 73.3% of patients (n=22) and clinical remission was sustained in 53.33% (n=16). Biochemical normalization occurred in 29.0% (n=11) and 30.0% (n=9) at 3 and 6 months, respectively. Additionally, 63.2% (n=24) and 43.3% of patients (n=13) achieved steroid-free clinical remission at 3 and 6 months, respectively. In the interim, one patient developed a serious infection requiring discontinuation of drug. Conclusions Our preliminary analysis demonstrates that in a real-life setting, tofacitinib is an effective treatment for inducing clinical remission in refractory UC patients. Further data will be complied to better assess the efficacy over a longer follow up. Funding Agencies None

Anxiety patient reported outcome tool (GAD-7) use in complementary medicine teaching clinics throughout Australia

ObjectiveTo assess how the introduction of the Generalized Anxiety Disorder-7 (GAD-7) was utilised in consultations by students in complementary medicine undergraduate teaching clinic throughout Australia. This study also aims to evaluate the reported severity of anxiety in patients attending the clinic, the practitioner type consulted, and the treatment prescribed by the Complementary Medicine (CM) students for patients with anxiety during 2017-18. DesignThis is a longitudinal, observational study using data from the Endeavour Wellnation clinics across Australia. MethodsPatients anxiety levels were measured with the GAD-7 at consultations with student practitioners during 2017–2018. Patients that completed the GAD-7 more than once had their subsequent GAD-7 scores compared to assess changes in outcome score. Information was taken from SurveyGizmo for patients who visited the student clinic making it a sub-group analysis. ResultsThree hundred and ninety (n = 390) GAD-7 surveys were completed from the 50, 896 consultations that occurred in 2017 and 2018 (0.7 % of consultations). Most patients (29.7 %, n = 116) reported moderate anxiety on several days. Thirty-nine patients (n = 39) completed the GAD-7 more than once. Nutrition patients were the most frequent to complete the GAD-7 more than once. ConclusionsThe introduction of the GAD-7 at Australian complementary medicine teaching clinics reported usage frequency of 0.7 % of consultations in the first two years. The reason for this usage frequency may be due to low encouragement of the use of Patient Reported Outcome Measurements (PROMs) by clinic supervisors and in pre-clinic subjects, students having low confidence in the use of the GAD-7 or other PROMs or lack of understanding of their benefits by either the student practitioner or the client. The lack of subsequent GAD-7 use in follow-up consultations may be contributing to a decreased substantiation of treatment outcomes for both the patient and the students. Consideration of more frequent use of the GAD-7 in regular clinical practice to enhance clinical outcomes and practitioner education is warranted.

Patients' and Caregivers' Attitudes Toward Deprescribing in Singapore.

Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs. A cross-sectional survey of two groups of participants was conducted using the Revised Patients' Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants' characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed. A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively. Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

Easily Conducted Tests During the First Week Post-stroke Can Aid the Prediction of Arm Functioning at 6 Months.

Background: Prognostic models can estimate the recovery of arm functioning after stroke, guide the selection of individual training strategies, and inform patient selection in clinical trials. Several models for early prediction of arm recovery have been proposed, but their implementation has been hindered by insufficient external validation, limited evidence of their impact on patient outcomes, and reliance on predictors that are not feasible in regular clinical practice.Objectives: To determine the predictive value of new and previously reported tests that can be easily conducted in regular clinical settings for early prognosis of two levels of favorable arm recovery at 6 months post-stroke.Methods: We performed a secondary analysis of merged data (n = 223) from two Scandinavian prospective longitudinal cohorts. The candidate predictors were seven individual tests of motor function and the sensory function measured by the Fugl-Meyer Assessment of Upper Extremity within 7 days post-stroke, and the whole motor section of this assessment. For each candidate predictor, we calculated the adjusted odds ratio (OR) of two levels of residual motor impairment in the affected arm at 6 months post-stroke: moderate-to-mild (≥32 points on the motor section of the Fugl-Meyer Assessment of Upper Extremity, FMA-UE) and mild (FMA-UE ≥ 58 points).Results: Patients with partial shoulder abduction (OR 14.6), elbow extension (OR 15.9), and finger extension (OR 9.5) were more likely to reach FMA-UE ≥ 32. Patients with full function on all individual motor tests (OR 5.5–35.3) or partial elbow extension, pronation/supination, wrist dorsiflexion and grasping ability (OR 2.1–18.3) were more likely to achieve FMA-UE ≥ 58 compared with those with absent function. Intact sensory function (OR 2.0–2.2) and moderate motor impairment on the FMA-UE (OR 7.5) were also associated with favorable outcome.Conclusions: Easily conducted motor tests can be useful for early prediction of arm recovery. The added value of this study is the prediction of two levels of a favorable functional outcome from simple motor tests. This knowledge can be used in the development of prognostic models feasible in regular clinical settings, inform patient selection and stratification in future trials, and guide clinicians in the selection of individualized training strategies for improving arm functioning after stroke.Clinical Trial Registration: ClinicalTrials.gov: NCT02250365, NCT01115348.

Implementing eHealth Interventions Into Regular Clinical Practice

Implementing eHealth Interventions Into Regular Clinical Practice

Obesity Prevalence and Determinants among Young Adults, with Special Focus on Normal-Weight Obesity; A Cross-Sectional Study in Mumbai.

Background:India has >135 million obese individuals at present. Body mass index (BMI) has been used to assess obesity until recent times. Later, studies have shown that central body fat (BF) measurements as a reliable predictor of metabolic diseases. Hence, normal-weight obesity (NWO) is defined. Those with a normal range of BMI but increased fat percentage are found to be having metabolic syndromes at a very early life. The young adult group is specifically focused on the study with diet and physical activity as potential determinants; as an intervention at the right time can prevent the development of many noncommunicable diseases.Objectives:The aim of this study is to estimate the prevalence of obesity and its determinants with special reference to NWO.Materials and Methods:A cross-sectional study was conducted based on diet, physical activity, and other lifestyle factors on a sample of 269 young adults. Using Harpenden skinfold calipers, BF percentage was calculated based on Jackson and Pollock and Siri's equation. Binary logistic regression was also applied appropriately.Results:The proportion of obesity was 42.01%, and that of NWO was 16.1%. Sex, high protein diet, number of restaurant visits, less homemade tiffin intake, heavy physical activity, alcohol intake were found to be significantly associated with obesity. Intake of fish, physical activity, protein diet, day-time sleep were found to be significantly associated with NWO.Conclusion:The study emphasizes the need for including BF percentage in addition to BMI in regular clinical practice. It may help in preventive and promotive efforts.

Implementation of the electronic medical record system in the radiation oncology department of a government health-care facility: A single-center experience

Background: The availability of electronic medical records (EMRs) in the health-care system has greatly helped to improve the quality of care provided to the patients. Installing an EMR system requires consideration of various factors such as the institutional structure, human resources, clinical workflow in the hospital, monetary issues, and coordination between the departments. Objectives: In this article, we have outlined the steps undertaken to integrate the EMR system into regular clinical practice in the department of radiation oncology. Materials and Methods: The EMR system was implemented in the department of radiation oncology of the Kidwai Memorial Institute of Oncology, a government health-care facility. The process of integration began in June 2019 and was completed in September 2019. We chose the MOSAIQ EMR software by Elekta systems for our center. The process involved creating a core team, establishing the workflow, customizing the software according to our hospital's clinical practices, installing computers, data storage and backup, entering the old patients' data and reports into the system, and training the staff. Results: The EMR system was made available for daily clinical practice from September 25, 2019. Since then, we observed a drastic reduction in the waiting time for the patient files to be made available at the outpatient department, as information could be accessed through EMR instantaneously. Furthermore, the patients' clinical data were available without any delay in the treatment planning system rooms, when planning radiation therapy (RT). Finally, in the radiation treatment rooms, EMRs allowed the RT technologists to obtain information regarding the number of fractions planned for a patient without any confusion as opposed to the earlier handwritten RT charts. Conclusion: The immediate advantage of the EMR system is the instantaneous availability of patient data in the hospital. However, the successful implementation and optimal use of this system require commitment from the health-care staff.

Teaching innovation in Biomedicine. A journey of approach to regular clinical practice. Research and its inclusion in a medical practice

Teaching innovation in Biomedicine. A journey of approach to regular clinical practice. Research and its inclusion in a medical practice

Development of an Index Score for Intestinal Inflammation-Associated Dysbiosis Using Real-World Stool Test Results

BackgroundGut microbiota play an important role in human health. However, the application of gut microbiome in regular clinical practice is limited by interindividual variations and complexity of test results.HypothesisIt is possible to address interindividual variation by using large data-based exploratory-pattern analysis.MethodsThe current study was conducted using a large data set (n = 173,221) of nonselective incoming patients’ test results from a stool test. The data set included assays for the detection of 24 selected commensal microorganisms and multiple biomarkers in feces. Patients were grouped based on their levels of inflammation biomarkers such as calprotectin, eosinophil protein X, and IgA. Group mean values of biomarkers and commensal microbes were used in an exploratory-pattern analysis for association from which an index score for intestinal inflammation-associated dysbiosis (IAD) was developed. The IAD score was evaluated in one questionnaire-based study (n = 7263) and one prospective case series study (n = 122) with patients of inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and celiac disease.ResultsWe identified a microbial profile strongly associated with fecal inflammation biomarkers. Developed on the pattern of the microbial profile, the IAD score demonstrated a strong association with fecal inflammation biomarkers and was significantly different between patients with IBD and those with IBS or celiac disease.ConclusionUsing real-world data, we have developed a method to predict gut dysbiosis associated with different GI disease conditions. It may help clinicians simplify the process of interpreting gut microbial status and provide gut health assessment and treatment evaluation.

P14.105 High incidence of brain metastases in lung cancer patients at the time of primary diagnosis

Abstract BACKGROUND Brain metastases (BM) affect 8%-10% of all cancer patients and 40% of patients with metastatic cancer. The majority of BM originate from lung cancer (40%-50%), breast cancer (15%-25%), and melanoma (5%-20%). Total incidence proportions percentage (IP %) of brain metastases was reported as 9.6% for all primary sites combined, and was highest for lung cancer (19.9%). The incidence of BM is believed to be increasing, likely resulting from longer patient survival due to more effective systemic therapies for the primary cancer and the increased use of neuroimaging in neurologically asymptomatic patients. MATERIAL AND METHODS Our aim was to determine incidence of brain metastases in lung cancer patients at the time of primary diagnosis on cohort of our regular clinical practice. Since September 2014 till December 2017 189 primarily diagnosed patients with suspected lung cancer were evaluated with brain MRI as obligatory part of diagnostic protocol at N.N. Blokhin Russian Cancer Research Center. MR imaging protocol included T1, T2-weighted images, FLAIR, DWI, VIBE (with contrast enhancement, slice thickness &lt;1.2 mm). According to diagnostic guidelines for lung cancer in Russia, all patients underwent chest CT scan with contrast enhancement, bronchoscopy, abdominal ultrasonography, ultrasonography of cervical lymph nodes (+ CT to evaluate detected abnormalities), bone scintigraphy with X-ray control of detected abnormalities, surgical removal (in case of T1-T2 tumor) or tumor biopsy to determine morphology. Additionally, all patients underwent Whole Body MR DWI, some patients received FDG-PET/CT scan. RESULTS Brain metastases were detected in 89 (48%) of 189 patients, while only 9 patients (10.1% of patients with brain metastases) had neurological deficits. Lesion sizes were as follows: 0.1–0.5 cm in 46 (51.7%) patients, 0.5–1.0 cm in 21 (23.6%) patients, 1.0–2.0 cm in 7 (7.9%) patients, 2.0–3.0 cm in 8 (9.0%) patients and &gt;3.0 in 7 (7.9% patients). The majority of patients (45 - 50.56%) had solitary metastases, 10 patients (11.24%) had two lesions and 34 (38.20 %) patients had three and more lesions. Metastatic disease most commonly affected frontal lobes - 45 (50.56%) patients, temporal lobes - 36 (40.45%) patients, parietal lobes - 22 (24.72%) patients, occipital lobes - 22 (24.72%), basal ganglia and brainstem - 18 (20.22%), - 3 (3.37%), cerebellum - 30 (33.71%) patients. Concerning morphology, in 80 of 89 brain metastases NSCLC was identified and in 9 patients SCLC was observed. CONCLUSION Very high incidence of brain metastases in lung cancer patients at the time of primary diagnosis in our study cohort may be explained by the use of precision brain MRI as an obligatory part of diagnostic protocol at the time of primary admission. We suggest including precision brain MRI in guidelines for primary diagnosis of lung cancer patients as an obligatory examination

Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden

BackgroundMany women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on...

Laboratory Work-Up of Chronic B-Cell Lymphoid Malignancies - A Value-Based Approach.

The aim of study was to summarize recent developments in laboratory work-up of lymphomas and discuss their clinical relevance. Diagnosis of lymphoma requires tissue biopsy with adequate work-up by pathologists. Recent developments in laboratory testing have raised the bar for establishing the diagnosis: more and more testing seems to be required, while the lines between research and clinical practice are being blurred. Academic medical practice is designed to push boundaries and test new hypotheses, which eventually result in improved patient care. Ability to (relatively) cheaply screen for multiple genomic abnormalities using new technologies is luring. Often, however, no change in patient management is pursued based on these results. It is therefore useful to review which testing is truly necessary from the patient's point of view. CONCLUSIONS: The laboratory work-up of lymphomas in a regular clinical practice requires relatively few tests. Many new tests have prognostic value, but do not necessarily contribute to the patient management.

The Effects of a Nurse-Led Education and Counseling Program on Dyspnea, Health Status, and Care Dependency in Patients With Chronic Obstructive Pulmonary Disease: A Feasibility Study

The aim of this feasibility study was to determine the effects of a nurse-led education and counseling program for chronic obstructive pulmonary disease (COPD-ECP) on dyspnea, health status, and care dependency in patients. A quasi-experimental, pre-posttest research design without a control group was performed on 30 COPD patients. The patients received an 8-week COPD-ECP via home visits during the first 4 weeks and via phone interviews in the subsequent 4 weeks. After completion of COPD-ECP and a 4-week break, a final follow-up was conducted at the end of 12th week. The Dyspnea-12, COPD Assessment Test (CAT), and Care Dependency Scale (CDS) scores were calculated during the first interview, and on the 4th, 8th, and 12th week of the study. The patients completed all sessions of COPD-ECP without side effects. There was a significant decrease in the total Dyspnea-12 scores at the end of the study period. Compared to the baseline assessment, CAT total scores significantly decreased in the 4th, 8th, and 12th week ( p &lt; 0.05), and CDS scores showed a significant reduction at the 12th week ( p &lt; 0.05). In conclusion, COPD-ECP is feasible in regular clinical practice and well accepted by patients, and it seems to improve health status and decrease dyspnea, and care dependency. Future randomized controlled studies are warranted to explore the effects of COPD-ECP on fatigue, cough and sleep problems, and the best innovative strategies to improve the efficiency of COPD-ECP.

Desarrollo de una Aplicación Móvil para la Evaluación Nutricional

Introducción: el uso de las llamadas apps o aplicaciones móviles está revolucionando el modo de trabajar en la práctica clínica. Aunque, actualmente es posible identificar gran cantidad de estas, en la revisión de la literatura no se hallan opciones como la propuesta por los autores.Objetivo: desarrollar una herramienta de uso sencillo que permita una orientación diagnóstica sobre el estado nutricional, con soporte normativo, disponible en diferentes plataformas móviles y pensanda para la ayuda al profesional sanitario en la praxis clínica.Métodos: Se realizó un consenso de expertos (grupo nominal y técnicas documentales) utilizando un método mixto mediante dos rondas presenciales (reunión de los participantes y aprobación de propuestas) y tres rondas enmascaradas (revisión del material de forma individual). El análisis se aplicó al ámbito de los diferentes niveles asistenciales.Resultados: Se desarrolló una aplicación móvil basada en algoritmos consensuados que permite dar una orientación diagnóstica sobre el estado nutricional y dar soporte en la toma de decisiones mediante algoritmos basados en los criterios médicos ampliamente aceptados en el ámbito de la nutrición.Conclusiones: la Herramienta de Evaluación Nutricional HEN se presenta como un apoyo a la práctica clínica habitual, facilitando el abordaje del estado nutricional de los pacientes en cualquier medio y entorno sanitario.

Toward an Expert Level of Lung Cancer Detection and Classification Using a Deep Convolutional Neural Network.

Computed tomography (CT) is essential for pulmonary nodule detection in diagnosing lung cancer. As deep learning algorithms have recently been regarded as a promising technique in medical fields, we attempt to integrate a well-trained deep learning algorithm to detect and classify pulmonary nodules derived from clinical CT images. Open-source data sets and multicenter data sets have been used in this study. A three-dimensional convolutional neural network (CNN) was designed to detect pulmonary nodules and classify them into malignant or benign diseases based on pathologically and laboratory proven results. The sensitivity and specificity of this well-trained model were found to be 84.4% (95% confidence interval [CI], 80.5%-88.3%) and 83.0% (95% CI, 79.5%-86.5%), respectively. Subgroup analysis of smaller nodules (<10 mm) have demonstrated remarkable sensitivity and specificity, similar to that of larger nodules (10-30 mm). Additional model validation was implemented by comparing manual assessments done by different ranks of doctors with those performed by three-dimensional CNN. The results show that the performance of the CNN model was superior to manual assessment. Under the companion diagnostics, the three-dimensional CNN with a deep learning algorithm may assist radiologists in the future by providing accurate and timely information for diagnosing pulmonary nodules in regular clinical practices. The three-dimensional convolutional neural network described in this article demonstrated both high sensitivity and high specificity in classifying pulmonary nodules regardless of diameters as well as superiority compared with manual assessment. Although it still warrants further improvement and validation in larger screening cohorts, its clinical application could definitely facilitate and assist doctors in clinical practice.

Antibiotics and probiotics for Helicobacter pylori infection

Eradication the infection of Helicobacter pylori is essential for the treatment of gastrointestinal diseases such as gastrointestinal ulcer and gastric cancer.Because of the increased resistance rate of H. pylori to antibiotics, clarithromycin triple therapy is no longer the best treatment for H. pylori, especially in some parts of the country with over 20% resistance to this antibiotic.Alternative therapies for eradicate of H. pylori have been proposed, including some new antibiotics or different combinations of classical antibiotics, which are used in regular clinical practice as a new and more effective treatment.Other treatments are antibiotic-related probiotics to treat the infection.The mechanism of which is not fully understood and needs further study. Key words: Helicobacter pylori; Sequential therapy; Clarithromycin; Probiotics

Use of the consolidated framework for implementation research to guide dissemination and implementation of new technologies in surgery.

Improving surgical outcomes is important to patients, providers, and healthcare systems. Understanding best methods to ensure evidence based practices are successfully implemented and sustained in clinical practices leads to improved care. Dissemination and implementation (D&I) science facilitates the successful pathway from clinical trials to sustained implementation. We describe D&I science, introduce the consolidated framework for implementation research (CFIR), a D&I framework, and provide an example of how CFIR was utilized to facilitate the translational process from design adaptations to implementation, broad utilization by clinicians, and sustainability of the SUrgical Risk Preoperative Assessment System (SURPAS) tool into regular clinical practice. SURPAS creates data-driven individualized risk assessments of common adverse postoperative outcomes to enhance the informed consent process, shared decision making, and consequently improved surgical outcomes. The CFIR provided a structured systematic way to identify constructs influencing the D&I of SURPAS, including adaptations for the process and tool. We identified three domains, each with specific constructs, that participants believed would strongly influence effectiveness of SURPAS implementation efforts: the importance of patients' perspectives (outer setting); the quality of SURPAS (intervention characteristic); and integration of SURPAS into the electronic health record (inner setting). Additionally, providers' positive attitudes toward and support of SURPAS (characteristics of individuals); and the ease of integration of SURPAS into the workflow (process), were also identified. Tension emerged between patients' preference of the provision of risk information and providers' concern about additional clinic time required for formal risk discussion with low-risk patients. Systematically identifying constructs from the beginning of the design through the implementation process can guide design of a multi-component strategy for future large-scale implementation by assessing the relative impact of factors on implementation using the CFIR framework. In the example studied, this allows key stakeholders to ensure success of D&I of SURPAS at multiple levels and times, continuously optimizing the process.