Use Of Standardized Terminology Research Articles

The Global Malnutrition Composite Score: Impacting malnutrition care.

The presence and impact of malnutrition in adult hospitalized patients has been well documented by a significant body of literature. However, current malnutrition care practices often vary widely and frequently lack standardization. The Global Malnutrition Composite Score (GMCS), the first nutrition-related electronic clinical quality measure, is intended to evaluate the quality of malnutrition care provided to inpatient adults. This measure aims to aid in standardizing malnutrition care through performance measurement. The four components of the measure (nutrition screening, nutrition assessment, malnutrition diagnosis, and nutrition care plans) follow the well-established Nutrition Care Process and encourage the use of standardized terminology. Facilities with high-performance scores on the GMCS are likely to experience improved outcomes associated with high-quality malnutrition care.

Effects of standardized language on remote ultrasound-guided percutaneous nephrolithotomy training: A mixed-methods explorative pilot study

BackgroundRemote teaching of procedural skills has demonstrated equivalence in knowledge acquisition compared to in-person teaching. Variations in terminology for probe and needle movements may serve as a barrier in remote training of ultrasound (US)-guided renal access for percutaneous nephrolithotomy (PCNL). This pilot study investigated the utility of standardized terminology in remote training of US-guided renal access for PCNL. HypothesisStandardization of verbal terminology to describe US probe and needle movement instruction improves remote teaching of US-guided renal access. MethodsFifteen urology residents (PGY1-6) were stratified by year and randomized into two groups. We provided participants with images illustrating US probe and needle movements labeled with predetermined standardized terminology for the intervention group and images without labels for the control group. Both groups were asked to perform US-guided renal access on a training mannequin with a remote faculty educator with (intervention) or without (control) use of standardized movement instructions. Quantitative outcomes included number of attempts and time to achieve access. All trainees completed pre- and post-session surveys and participated in focus groups; authors conducted thematic analysis of focus group transcripts. ResultsDifferences in primary outcomes between groups, including number of attempts and time to achieve access of the renal pole, were not statistically significant. Analysis of focus group interviews revealed that the use of standardized terminology in the setting of remote training can reduce trainee confusion by clarifying ambiguity in educator feedback. DiscussionUse of standardized terminology during remote surgical skills training allows for more effective feedback to trainees.

Auras in Persons with Focal and Generalized Epilepsy: Types and Patient Numbers from a Tertiary Level Epilepsy Center (P12-1.001)

<h3>Objective:</h3> We aimed to identify types and frequency of auras in patients with focal and generalized epilepsy. <h3>Background:</h3> The present-day knowledge of auras in persons with epilepsy (PWE) suggests a variety of experiences before seizure onset. A multitude of studies correlate them with focal epilepsy, although auras experienced by patients with generalized epilepsy have also been frequently reported. <h3>Design/Methods:</h3> This was a cross-sectional retrospective data analysis of 1505 PWE. We included patients who were diagnosed clinically as focal or generalized epilepsy along with corresponding changes on EEG and/or Long-Term Monitoring Evaluation (LTME). All patients in the study were inquired about consistent subjective feelings before seizure onset and these were classified as auras. <h3>Results:</h3> The database consists of 1505 patients out of which 1176 are diagnosed with focal and 253 diagnosed with generalized epilepsy. These patients were 47.2% male and 52.8% female, mean age 41.09±22.07 years. Available EEG/LTME results with focal discharges were seen in 214/1176 (18.1%) patients with focal epilepsy and generalized discharges in 127/253 (50%) patients with a diagnosis of generalized epilepsy. Auras were found to be more common in patients in the focal epilepsy (27%) than generalized epilepsy (16%). Most common auras reported in focal epilepsy included feeling of confusion (21%), visual symptoms (18%) and somatosensory (11%). In generalized epilepsy, non-specific auras were most commonly noted including, feeling of confusion (30%), dizziness (25%) and somatosensory (10%). Vague and non-descript auras were reported in 19% of patients with focal epilepsy and 25% of those with generalized epilepsy. <h3>Conclusions:</h3> Approximately one-third of patients with EEG confirmed diagnosis of focal epilepsy experience auras. Although less frequently, generalized epilepsy patients also report auras. Use of standardized terminology for identifying auras might help address the variations reported. More studies are needed to identify the electrophysiological phenomena associated with them. <b>Disclosure:</b> Mr. Asghar has nothing to disclose. Dr. Naz has nothing to disclose. Dr. Ramsey-Williams has nothing to disclose. Dr. Sheikh has nothing to disclose. Dr. Saleem has nothing to disclose. Dr. Pervez has nothing to disclose. Dr. Ali has received personal compensation in the range of $10,000-$49,999 for serving as an officer or member of the Board of Directors for ABPN. Dr. Riaz has nothing to disclose.

A Scoping Review of Retrieval Practice (Test-Enhanced Learning) in Nursing Education.

The aim of this study was to determine the status of retrieval practice in original research of nursing education. The science of learning is an emerging interdisciplinary field that offers evidence-based strategies to improve learning. One of the most highly effective strategies is retrieval practice, which involves recalling previously learned information from long-term memory prior to additional study. Searching PubMed, CINAHL, Scopus, Psych INFO, and ERIC, an interprofessional team followed a formal scoping review framework and utilized the PRISMA Extension for Scoping Reviews to report the findings. The review included 25 research studies, with all but one at the prelicensure level. Quantitative designs were most common, and outcomes reflected objective and subjective measures. If present, terms were varied and inconsistent with supporting research. Documentation of many characteristics was lacking. Retrieval practice is an increasingly common strategy being studied at the prelicensure level. Opportunities for improvement include consistent use of standard terminology, documentation of important characteristics, and more attention to subjective outcomes and to graduate and continuing education levels.

MR Defecating Proctography with Emphasis on Posterior Compartment Disorders.

MR defecating proctography (MRDP) is a noninvasive examination that can be used for evaluating posterior compartment disorders. MRDP has several advantages over conventional fluoroscopic defecography. These benefits include high-contrast resolution evaluation of the deep pelvic organs, simultaneous multicompartmental assessment that is performed statically and dynamically during defecation, and lack of ionizing radiation. MRDP also provides a highly detailed anatomic evaluation of the pelvic floor supportive structures, including direct assessment of the pelvic floor musculature and indirect assessment of the endopelvic fascia. As the breadth of knowledge regarding anatomic and functional posterior compartment disorders expands, so too does the advancement of noninvasive and surgical treatment options for these conditions. High-quality MRDP examinations, with key anatomic and functional features reported, guide treatment planning. Reporting of MRDP examination findings with use of standardized terminology that emphasizes objective measurements rather than subjective grading aids consistent communication among radiologists, clinicians, and surgeons. Familiarity with commonly encountered posterior compartment pelvic floor pathologic entities that contribute to posterior compartment disorders and awareness of the essential information needed by surgeons are key to providing an optimal multidisciplinary discussion for planning pelvic floor dysfunction treatment. The authors provide an overview of the basic concepts of the MRDP acquisition technique, the anatomic abnormalities of posterior compartment pelvic floor pathologic entities associated with defecatory disorders, and recently developed interdisciplinary MRDP reporting templates and lexicons. In addition, the associated imaging findings that are key for surgical treatment guidance are highlighted. © RSNA, 2022 Online supplemental material is available for this article.

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions.

To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data. A sample of 10399324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm. The number of drug product description variants for each RxCUI was determined. Variants identified were compared to RxNorm to determine the extent of matching terminology used. A total of 353002 unique pairs of drug product descriptions and NDCs were analyzed. The median (1st-3rd quartile) number of variants extracted for each standardized expression in RxNorm, was 3 (2-7) for ingredients, 4 (2-8) for strength, and 41 (11-122) for dosage forms. Of the pairs, 42.35% of ingredients (n = 328032), 51.23% of strengths (n = 321706), and 10.60% of dose forms (n = 326653) used matching terminology, while 16.31%, 24.85%, and 13.05% contained nonmatching terminology, respectively. A wide variety of drug product descriptions makes it difficult to determine whether 2 drug product descriptions describe the same drug product (eg, using abbreviations to describe an active ingredient or using different units to represent a concentration). This results in patient safety risks that lead to incorrect drug products being ordered, dispensed, and used by patients. Implementation and use of standardized terminology may reduce these risks. Drug product descriptions on real-world e-prescriptions exhibit large variation resulting in unnecessary ambiguity and potential patient safety risks.

Using data visualization to detect patterns in whole-person health data.

Data visualization techniques are useful for examining large multidimensional data sets. In this exploratory data analysis (EDA) study, we applied a visualization pattern detection and testing process to deidentified data to discover patterns in whole-person health for adults 65 and older. Whole-person health examines a person's environmental, psychosocial, and physical health, as well as their health-related behaviors; and assesses their strengths, challenges, and needs. Strengths are defined as assets and capabilities in the face of short-or long-term stressors. We collected data using a mobile application that delivers a comprehensive whole-person assessment using a simplified version of a standardized instrument, the Omaha System. The visualization pattern detection process is iterative, includes various techniques, and requires visualization literacy. The data visualization techniques applied in this analysis included bubble charts, parallel coordinates line graphs, box plots, and alluvial flow diagrams. We discovered six patterns within the visualizations. We formulated and tested six hypotheses based on these six patterns, and all six hypotheses were supported. Adults 65 and older had more strengths than challenges and more challenges than needs (p < 0.001). Strengths and challenges were negatively correlated (p < 0.001). Unexpectedly, a subset of adults 65 and older who had many, but not all, strengths had significantly more needs (p = 0.04). The use of standardized terminology with its inherent data interrelationships was key to discovering patterns in whole-person health. This methodology may be used in future EDA research using new data sets.

An annotated catalogue of the exotic flora of Angola: state of the art

Data and information provided in a 2008 floristic inventory of the indigenous and exotic flora of Angola was disaggregated and reanalysed for an improved understanding of the floristic component that is non-indigenous to the country. Results of the analysis are presented here as a catalogue of the exotic flora recorded for Angola. The catalogue consists of three lists: 1. ‘Naturalised aliens’; 2. ‘Taxa of uncertain indigenous or naturalised status or presence’; and 3. ‘Cultivated, casual, and escaped taxa’. Overall, the catalogue is expanded, brought up to date, and evidence-based information is provided for each taxon included on one of the three lists. A total of 180+ taxa are recorded here as having become naturalised in Angola. This figure includes records at the rank of genus that likely include more than one species. A further 53 taxa of uncertain indigenous or naturalised status or presence are listed. Additionally, 110 taxa that are cultivated, casual, or escaped are discussed. We compare the figures presented here to those available for a selection of other countries. We show that, in terms of numbers, the non-indigenous flora of Angola is smaller than that of some near-neighbouring countries, such as Zimbabwe (to the east) and South Africa (to the south), and argue for the use of standard terminology when recording and referring to non-indigenous species, and for the preparation of herbarium vouchers when such species are encountered.

Creating qualitative datasets in geoarchaeology: An easy-applicable description template for archaeological thin section analysis using Stoops 2003

Micromorphological thin section analysis is a powerful method in geoarchaeology to study deposits at archaeological sites. The approach is largely borrowed from soil science and relies on standard descriptive terminology established by [9] and others. Within archaeological micromorphology, we encounter two main issues with thin section description: (1) Anthropogenic deposits are highly variable when compared to purely natural deposits and soils and (2) many practitioners of archaeological micromorphology come from a range of backgrounds and experiences. Therefore, despite the use of standardized terminology, the qualitative nature of thin section description results in a high degree of variation amongst practitioners in the description and documentation of thin sections, particularly amongst beginners in the field.Here, we propose:•A template that can help to understand and remember the terminology, so that it can be an easy-to-use tool for beginners.•A template with better inclusion of anthropogenic material and features to better fit the needs of archaeological sites.•A way of documenting data from a thin section analysis, that results in understandable, reproducible, and shareable datasets that can be easily integrated with databases.

Terms and Definitions Used to Describe Recurrence, Treatment Failure and Recovery of Acute Exacerbations of COPD: A Systematic Review of Observational Studies.

IntroductionAcute exacerbations of chronic obstructive pulmonary disease (AECOPDs) are important clinical events, with many patients experiencing multiple AECOPDs annually. The terms used in the literature to define recurring AECOPD events are inconsistent and may impact the ability to describe the true burden of these events. We undertook a systematic review to identify and summarize terms and definitions used in observational studies to describe AECOPD-related events occurring after an initial AECOPD (hereafter “subsequent AECOPD”).MethodsPubMed was searched (2000–2019) for observational studies on subsequent AECOPD events using broad search strings for “COPD”, “exacerbation”, and “subsequent exacerbation events”. Only English-language studies were included. Small studies (n<50) and studies focusing on hospital re-admission only were excluded. Extracted data were analyzed descriptively to generate a narrative summary, using a thematic approach to group studies utilizing similar terms for subsequent AECOPD.ResultsForty-seven studies were included. No single, distinct terms or definitions were used to define and identify multiple occurrences of AECOPDs, though most (46) studies used one or more of four clustered terms and definitions: reapse (n = 13), recurrence/re-exacerbation (n = 11), treatment failure (n = 12) and non-recovery/time to recovery (n = 16). Heterogeneity was observed within and between the four clusters with respect to study setting, starting point for observing subsequent AECOPDs, time frame to identify a subsequent AECOPD (except for studies using “time to recovery”), and basis for identifying a subsequent exacerbation.ConclusionOur review demonstrates that subsequent AECOPDs (including events such as relapse, recurrence/re-exacerbation, treatment failure, non-recovery/time to recovery) are ill-defined in the observational study literature, emphasizing the need to reach consensus on precise and objective definitions (for example, when one AECOPD ends and another begins). Use of standardized terminology and definitions may aid comparability between, and synthesis of, studies, thus improving the understanding of the natural history and burden of exacerbations in COPD patients.

The estimand framework and its application in substance use disorder clinical trials: a case study

ABSTRACT Relapse rates among individuals with substance use disorder (SUD) remain high and new treatment approaches are needed, which require evaluation in randomized controlled trials (RCTs). Measurement and interpretation challenges for SUD RCT data are often ignored or presented only in statistical analysis plans. Since different analytic approaches may result in different estimates and thus interpretations of the treatment effect, it is important to present this clearly throughout the trial. Inconsistencies between study analyses and objectives present further challenges for interpretation and cross-study comparisons. The recent International Council for Harmonization (ICH) addendum provides standardized language and a common framework for aligning trial objectives, design, conduct, and analysis. The framework focuses on estimands, which describe the treatment effect and link the trial objective with the scientific question and the analytic approach. The use of estimands offers SUD researchers and clinicians the opportunity to explicitly address events that affect measurement and interpretation at the outset of the trial. Furthermore, the use of standard terminology can lead to clearer interpretations of SUD trials and the treatments evaluated in SUD trials. Resources for understanding and applying estimands are needed to optimize the use of this new, helpful framework. This Perspective provides this resource for SUD researchers. Specifically, it highlights the relevance of estimands for SUD trials. Furthermore, it demonstrates how estimands can be used to develop clinically relevant analyses to address challenges in SUD trials. It also shows how a standardized framework can be employed to improve the interpretation and presentation of SUD study findings.

Evaluating Systemized Nomenclature of Medicine Clinical Terms Coverage of Complementary and Integrative Health Therapy Approaches Used Within Integrative Nursing, Health, and Medicine.

The use of complementary and integrative health therapy strategies for a wide variety of health conditions is increasing and is rapidly becoming mainstream. However, little is known about how or if complementary and integrative health therapies are represented in the EHR. Standardized terminologies provide an organizing structure for health information that enable EHR representation and support shareable and comparable data; which may contribute to increased understanding of which therapies are being used for whom and for what purposes. Use of standardized terminologies is recommended for interoperable clinical data to support sharable, comparable data to enable the use of complementary and integrative health therapies and to enable research on outcomes. In this study, complementary and integrative health therapy terms were extracted from multiple sources and organized using the National Center for Complementary and Integrative Health and former National Center for Complementary and Alternative Medicine classification structures. A total of 1209 complementary and integrative health therapy terms were extracted. After removing duplicates, the final term list was generated via expert consensus. The final list included 578 terms, and these terms were mapped to Systemized Nomenclature of Medicine Clinical Terms. Of the 578, approximately half (48.1%) were found within Systemized Nomenclature of Medicine Clinical Terms. Levels of specificity of terms differed between National Center for Complementary and Integrative Health and National Center for Complementary and Alternative Medicine classification structures and Systemized Nomenclature of Medicine Clinical Terms. Future studies should focus on the terms not mapped to Systemized Nomenclature of Medicine Clinical Terms (51.9%), to formally submit terms for inclusion in Systemized Nomenclature of Medicine Clinical Terms, toward leveraging the data generated by use of these terms to determine associations among treatments and outcomes.

20 Standardized terminology of apical structures in the female pelvis

The objective of this video is to serve as a visual aid for the standardized terminology of the apical structures by presenting the accepted English terms in Terminologia Anatomica and newly proposed terms by the Society of Gynecologic Surgeons Pelvic Anatomy Group. By using cadaveric dissections and operating room footage we review the preferred and non-preferred terms of common structures in the apical compartment of the female pelvis. Additionally, we present the newly proposed terms by the Anatomy Group systematic review. These terms were proposed to be used in communication, particularly intraoperatively with respect to surgical anatomy. Although many of these structures are basic and common knowledge to gynecologists, this video focuses on clarifying the preferred terminology to use when discussing these structures and proposes new names to structures or regions that are clinically or surgically useful. We encourage the use of standardized terminology when speaking, writing, and teaching about female pelvic anatomy.

Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review

Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise. Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding. From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review. Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication. This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

Concise Reporting of Benign Endometrial Biopsies is an Acceptable Alternative to Descriptive Reporting.

In the United Kingdom, endometrial biopsy reports traditionally consist of a morphologic description followed by a conclusion. Recently published consensus guidelines for reporting benign endometrial biopsies advocate the use of standardized terminology. In this project we aimed to assess the acceptability and benefits of this simplified "diagnosis only" format for reporting non-neoplastic endometrial biopsies. Two consultants reported consecutive endometrial biopsies using 1 of 3 possible formats: (i) diagnosis only, (ii) diagnosis plus an accompanying comment, and (iii) the traditional descriptive format. Service users were asked to provide feedback on this approach via an anonymized online survey. The reproducibility of this system was assessed on a set of 53 endometrial biopsies among consultants and senior histopathology trainees. Of 370 consecutive benign endometrial biopsies, 245 (66%) were reported as diagnosis only, 101 (27%) as diagnosis plus a brief comment, and 24 (7%) as diagnosis following a morphologic description. Of the 43 survey respondents (28 gynecologists, 11 pathologists, and 4 clinical nurse specialists), 40 (93%) preferred a diagnosis only, with 3 (7%) being against/uncertain about a diagnosis only report. Among 3 histopathology consultants and 4 senior trainees there was majority agreement on the reporting format in 53/53 (100%) and 52/53 (98%) biopsies. In summary, we found that reporting benign specimens within standardized, well-understood diagnostic categories is an acceptable alternative to traditional descriptive reporting, with the latter reserved for the minority of cases that do not fit into specific categories. This revised approach has the potential to improve reporting uniformity and reproducibility.

New species and new records of Phragmatopoma (Polychaeta: Sabellariidae) from Tropical America

The genus Phragmatopoma included, until now, only four valid species with distributions in Eastern Pacific and Western Atlantic. Since most taxonomic studies of Phragmatopoma include poor and uninformative descriptions, the aim of this work was to expand previous descriptions of the sabellariids of Phragmatopoma genus from Tropical America. Sabellariids from two Mexican collections, the Reference Collection of El Colegio de la Frontera Sur, Chetumal, and Laboratorio de Sistemática de Invertebrados Marinos (LABSIM), Universidad del Mar, Puerto Ángel, were revised. Six hundred sixty-six specimens were revised, and eight species were identified. Three new species are proposed: Phragmatopoma balbinae n. sp., from southern Mexican Pacific, P. carlosi n. sp., from northern Mexican Pacific and P. villalobosi n. sp., from Pacific of Costa Rica. Another morphospecies, Phragmatopoma sp., from Pacific of Costa Rica is characterized; however, it is only one specimen. Two species, Phragmatopoma digitata and P. peruensis, previously buried in the synonyms of P. virgini (type locality: Straits of Magellan, Chile), are considered as valid species. Also, new records of P. californica and P. caudata were made in Baja California and Veracruz, respectively. Additionally, the use of standard terminology for the description of opercular paleae and chaetae is proposed.

Human surface anatomy terminology for dermatology: a Delphi consensus from the International Skin Imaging Collaboration.

There is no internationally vetted set of anatomic terms to describe human surface anatomy. To establish expert consensus on a standardized set of terms that describe clinically relevant human surface anatomy. We conducted a Delphi consensus on surface anatomy terminology between July 2017 and July 2019. The initial survey included 385 anatomic terms, organized in seven levels of hierarchy. If agreement exceeded the 75% established threshold, the term was considered 'accepted' and included in the final list. Terms added by the participants were passed on to the next round of consensus. Terms with <75% agreement were included in subsequent surveys along with alternative terms proposed by participants until agreement was reached on all terms. The Delphi included 21 participants. We found consensus (≥75% agreement) on 361/385 (93.8%) terms and eliminated one term in the first round. Of 49 new terms suggested by participants, 45 were added via consensus. To adjust for a recently published International Classification of Diseases-Surface Topography list of terms, a third survey including 111 discrepant terms was sent to participants. Finally, a total of 513 terms reached agreement via the Delphi method. We have established a set of 513 clinically relevant terms for denoting human surface anatomy, towards the use of standardized terminology in dermatologic documentation.

Disorders of Sex Development: A 5-year Review of Patients at a Tertiary Care Hospital

Background. Disorders of Sex Development (DSD) are conditions that arise from an abnormality of the typical structural, chromosomal and/or gonadal characteristics of sex development. The incidence of DSD is not well established in the Philippines and there is no published local data. The complex nature of DSD requires streamlined multidisciplinary team management and guidelines from the 2006 Consensus meeting have become the standard of care for patients.Objective. The study describes the phenotype, biochemical, diagnostic and management profiles of patients with Disorders of Sex Development (DSD) excluding congenital adrenal hyperplasia (CAH) at the Philippine General Hospital, a tertiary care medical facility.Methods. Medical records of patients with DSD seen at the Division of Clinical Genetics from 2012-2016 were reviewed. Histories, demographic profiles, clinical features, co-existing health conditions, laboratory, imaging results, and interventions (medical or surgical) were recorded into a clinical report form.Results. Fifty-five (55) patient charts were included of all the patients with DSD listed in the registry. The neonatal period was the most common time DSD was first noted (69.09%). Most (58.18%) were assigned the male sex. The most common genital anomalies were hypospadias (45.45%), cryptorchidism (21.82%), and micropenis (12.73%). Associated health conditions included multiple congenital anomalies (32.73%), genitourinary with or without gastrointestinal anomalies (16.36%) and dysmorphic features (12.73%). Among 28patients with karyotypes, there were 12 patients with sex chromosome DSD; two 46, XX DSD and fourteen 46, XY DSD. Four patients were prescribed hydrocortisone, three of whom had higher levels of 17-OH progesterone beyond cut-off level (2 preterm, 1 full term) while 1 full term presented with genital ambiguity; one case of Klinefelter syndrome was given testosterone replacement. Ten patients underwent corrective surgery for urogenital anomalies. Repair of hypospadias was the most common procedure. Repairs of associated anomalies (neurologic, cardiac, gastrointestinal, genitourinary) were done in 6 patients.Conclusion. Complete history, meticulous physical examination and comprehensive investigations are important for the confirmation of DSDs. Uniform classification, use of standardized terminology, and proper documentation of findings are crucial for the integrated and appropriate management of these patients.

Cross-enterprise interoperability : Challenges and principles for technical implementation

Demographic change, the migration of medical professionals and economic constraints are leading to an increasing specialisation and concentration of resources in the healthcare sector. The digital mapping of cross-enterprise process chains between different medical care levels in turn requires digital networking and syntactical and semantical interoperability in information exchange. Cross-enterprise electronic patient records based on the Cross-Enterprise Document Sharing (XDS.b) integration profile defined by the Integrating the Healthcare Enterprise (IHE) initiative are the basis of the digital exchange of medical information between patients and service providers. Syntactical interoperability is ensured by the object definitions in the XDS Affinity domain and the Clinical Document Architecture (CDA) document format. Semantical interoperability is achieved by the use of standardized terminology and code systems. Terminology servers make it easy to deploy standard ontologies and translate proprietary code systems. New interoperability standards, e.g. based on Fast Healthcare Interoperability Resources (FHIR), are being developed to facilitate the exchange of structured medical information objects on mobile platforms in the future.

Developing Structured Omaha System Goals for Use in an Electronic Health Record.

Use of standardized terminology has been essential for clear, concise, and accurate documentation of client assessments, care plans, and outcomes. The purpose of this study was to create standardized language goals for a case management system that used the Omaha System. A group of nursing informaticists analyzed, refined, and developed revised goals evaluated using medical vocabulary properties. A set of unique goals aligned with the Omaha System was developed with specifically designed characteristics and functionality that allowed individualization and evaluation of goal attainment. Goal statements and ratings were standardized and written to reflect goals a client could attain. The Omaha System goals served as a template for nurse case managers to use in telephonic support with clients and future development of new goals and allowed the organization the ability to generate quality metrics.