Validación y Comparación de un Nuevo Método para Predecir el Ancho Mesiodistal de Caninos y Premolares no Erupcionados en una Población Chilena de la Región de Valparaíso, Chile

Uno de los principales problemas durante la dentición mixta es la determinación de la futura discrepancia entre tamaño dentario y el espacio disponible. Para predecir el ancho mesiodistal de los dientes permanentes no erupcionados se han introducido diferentes métodos de análisis. Objetivo: El propósito de este estudio fue comparar el método Tanaka-Johnston con una nueva ecuación de regresión para predecir el ancho mesiodistal de caninos y premolares permanentes no erupcionados en una población de la región de Valparaíso, Chile. Material y método: Este estudio fue realizado en la Facultad de Odontología de la Universidad de Valparaíso, desde octubre de 2022 a junio de 2023 (8 meses), la muestra estuvo compuesta por 202 modelos de estudio del departamento de ortodoncia (91 hombres y 111 mujeres) en el rango de edad de 11 -20 años. Resultados: Se demostró que el método elaborado por Lara-Sandoval presenta mayor fiabilidad respecto a las medidas mesiodistales reales de los pacientes (ICC 0,773 para maxilar y 0,762 para mandíbula), en comparación con el método de Tanaka-Johnston (ICC 0,665 para maxilar y 0,623 para mandíbula). No existen diferencias significativas entre los valores reales y el método de Lara-Sandoval. Conclusión: El método de Lara-Sandoval es mejor que el propuesto por Tanaka-Johnston para determinar el ancho mesiodistal de caninos y premolares para esta muestra. Es necesario validar este método en otras regiones del país para ser utilizado con mayor seguridad que el ya existente como método estándar nacional.

One of the main orthodontic problems in mixed dentition is the determination of future tooth and size arch discrepancy. In order to predict the mesiodistal widths of unerupted permanent teeth different methods of analyses have been introduced. The aim of this study is to compare the Tanaka-Johnston analysis with a new regressive equation to predict the mesiodistal width of unerupted permanent canines and premolars in a Chilean population sample, from Valparaíso region. This study was conducted at the Universidad de Valparaíso Dental Faculty, from october 2022 to june 2023 (8 months), and the sample comprised historical dental casts from 202 patients (91 boys and 111 girls) in the age range of 11-20 from the orthodontics department. All the patients are from the Valparaíso region, Chile. The results show that the predictions of the new regressive equation method are closer to the actual mesiodistal measurements of the patients (ICC 0,773 for maxilla and 0,762 for mandible), compared to the Tanaka- Johnston method (ICC 0,665 for maxilla and 0,623 for mandible). There are no significant differences between the real values and the Lara-Sandoval method. Lara-Sandoval method is better than the one proposed by Tanaka-Johnston to determine the mesiodistal width of canines and premolars in this sample population. It is necessary to validate this method in other regions of the country to be used with greater security than the ones that already exists as a national standard method.

Analysis of Watson for oncology and clinicians� treatment recommendations for patients with breast cancer in Korea: A single center experience

Background: Various clinical applications have been attempted using artificial intelligence (AI) clinical decision support system (CDSS), and it has become a starting point for personalized cancer treatment. We aimed to identify the degree of agreement between the AI?CDSS, Watson for Oncology (WFO), and the clinician in treatment recommendations for Korean breast cancer patients and to provide guidelines for future improvement. Methods: One hundred and eighty?three breast cancer patients who underwent treatment at the Pusan National University Hospital between January 1, 2016 and May 31, 2017 were enrolled in this study. The concordance between WFO抯 and clinicians� treatment recommendations were examined according to various factors. Results: WFO gave the same treatment option recommendations as clinicians in 74 (40.4%) of the cases. According to the logistic regression, the difference in recommendation concordance between stage I and stage III was statistically significant (P = 0.004), and there was no difference among other factors. Conclusion: The concordance of treatment recommendations was low overall. However, this is largely attributable to the differences of medical insurance system and healthcare environment between the United States and Korea. In the future, region?specific features should be considered or reflected during the development of AI?CDSS.

How an electronic prescription tool enables better prescription quality for patients

Objective: Medication-related errors in patients are among the leading causes of preventable health damage and harm worldwide. In the United States, these errors cause at least one death a day and damage approximately 1.3 million people annually. According to the World Health Organization, the global expenditure on medication-related errors is estimated to be U$ 42 billion per year. In Brazil, the rate of potential drug interactions varies between 28% and 63.6% for primary care patients. The prevalence of drug interactions has increased following an aging population, increased chronic conditions, combined use of different drugs, and increased prescription drugs per patient. Methods: The data used for this study were obtained through the database from Nexodata do Brasil S.A a private health technology company with an electronic prescription system and a data intelligence area. Results: 65,867 electronic prescriptions were evaluated during 2019. Of these, 4,828 prescriptions had an average of 2.5 interactions. These interactive prescriptions were generated by 197 different doctors, totaling 24.5 prescriptions with interaction per doctor over 12 months. A total of 12,005 interactions were identified, 15.6% classified as mild, 70.9% as moderate, and 13.5% as severe. Conclusion: By implementing an electronic prescription tool, a reduction of 32.9% in the number of prescriptions with drug interaction was observed.

Evidências na COVID-19: atenção primária, telessaúde e atenção hospitalar / Evidence in COVID-19: primary care, telehealth and hospital care

Introdução: A pandemia da COVID-19 representa um grande desafio para os sistemas de saúde de todo o mundo, com demandas sem precedentes em todos os níveis de atenção à saúde. Na atenção primária, além do cuidado dos indivíduos com sintomas gripais, a descontinuidade do acompanhamento de pacientes com doenças crônicas é causa de grande preocupação. Na atenção hospitalar, a necessidade imediata de assistir pacientes com formas graves e críticas da COVID-19, exigiu ampliação de leitos convencionais e de cuidados intensivos, recursos tecnológicos para suporte avançado de vida e capacitação em tempo recorde, à medida que avançavam os conhecimentos sobre a doença. Objetivos: O presente trabalho possui dois objetivos principais. Objetivo 1: Avaliar o impacto da pandemia da COVID-19 em uma coorte de pessoas com hipertensão e diabetes na atenção primária, além de desenvolver e implementar uma solução digital para melhorar o monitoramento no domicílio. Objetivo 2: Avaliar se o escore de risco ABC2-SPH é capaz de predizer a necessidade de ventilação mecânica em pacientes com COVID-19 e comparar seu desempenho ao de outros escores desenvolvidos para predizer ventilação mecânica, mortalidade e outros desfechos, inclusive em pacientes não COVID. Métodos: Para alcançar o objetivo 1: Foi desenvolvido um estudo multimetodológico. Uma avaliação quasi-experimental analisou o impacto da pandemia na frequência de consultas e controle de pacientes com hipertensão e diabetes em 34 unidades básicas de saúde (UBS) em 10 municípios do Vale do Mucuri, Minas Gerais, entre junho de 2017 e dezembro de 2020, considerando como ponto de corte o dia 14 de março de 2020, quando as medidas de restrição social tiveram início. Em seguida, um estudo de factibilidade desenvolveu um aplicativo com um sistema de apoio à decisão (SAD) para agentes comunitários de saúde (ACS) para identificar, durante a visita domiciliar, pacientes com hipertensão arterial (HAS) e/ou diabetes mellitus (DM) não controlados e referenciá-los para atendimento presencial na UBS. Um painel de especialistas avaliou a viabilidade, usabilidade e utilidade do aplicativo através de questionário específico. Para alcançar o objetivo 2: Estudo de coorte retrospectiva, derivado do estudo originalmente chamado "Avaliação do perfil laboratorial, radiológico e sintomatológico de pacientes infectados com o novo coronavírus 2019 (SARS-CoV-2) em hospitais do estado de Minas Gerais" que se tornou um estudo multicêntrico, realizado em 31 hospitais, em 17 cidades de cinco estados. O estudo incluiu pacientes que foram internados em dois períodos: março a setembro de 2020 e março a dezembro de 2021, com diagnóstico de COVID-19 confirmado. Neste estudo, o escore de risco ABC2-SPH, desenvolvido para predição de mortalidade intra-hospitalar por COVID-19, foi avaliado quanto à possibilidade de predizer a necessidade de ventilação mecânica e comparado a outros escores: CALL, PREDI-CO, SUM, STSS, COVID_IRS_NLR, CURB-65, SOFA e 4C Mortality Score. Resultados: Objetivo 1: Dos 5070 pacientes, 4810 (94,9%) tinham HAS, 1371 (27,4%) tinham DM e 1111 (23,1%) tinham as duas doenças. Houve redução significativa no número de consultas semanais quando comparados o período antes e depois do início das medidas de restrição social (107 [IQR 60,0, 153,0] vs 20,0 [IQR 7,0, 29,0], respectivamente, p <0,001. Apenas 15,2% de todos os pacientes retornaram para consulta durante a pandemia. Indivíduos com HAS que retornaram tinham níveis de pressão arterial sistólica (120,0 [IQR 120,0-140,0]) e diastólica (80,0 [IQR 80,0-80,0]) menores do que os níveis apresentados antes da pandemia por aqueles que não retornaram (130,0 [IQR 120,0-140,0] e 80,0 [IQR 80,0-90,0]), p<0,001. Além disso, aqueles que retornaram tiveram uma proporção maior de HAS controlada (64,3% vs 52,8%). Para o DM, não houve diferenças nos níveis de glicohemoglobina. Em relação ao SAD, os especialistas concordaram que os ACS podem incorporá-lo facilmente em suas rotinas e o aplicativo pode identificar pacientes em risco e melhorar o tratamento. Objetivo 2: Ao longo do estudo, foram incluídos 4.831 pacientes, com idade mediana de 59,0 (IQR 48,0, 70,0) anos e 46,3% do sexo feminino. Destes, 34,2% necessitaram de tratamento intensivo, 26,6% necessitaram de VMI e 18,7% faleceram. Os pacientes que necessitaram de VMI apresentaram maior prevalência de HAS, DM, obesidade e mortalidade quando comparados aos que não necessitaram (64,3% vs 2,3%, p<0,001). Com base no conjunto de dados imputados, o ABC2-SPH apresentou AUROC 0,677 (IC 95% 0,681-0,694). Considerando apenas os casos completos, a AUROC foi de 0,70 (IC 95% 0,68-0,72), tendo o melhor desempenho entre os escores com amostras maiores de casos completos. No geral, as discriminações dos escores foram de regular a ruim. O SOFA Score teve a maior sensibilidade, 0,84 (IC 95% 0,81-0,86). O escore SOFA teve a maior sensibilidade 0,84 (IC 95% 0,81-0,86). Conclusões: A pandemia da COVID-19 causou uma queda significativa no número de consultas de pacientes com HAS e DM na atenção primária. Um SAD para ACS mostrou-se viável e útil para identificar pacientes descontrolados em casa. O escore ABC2-SPH demonstrou melhor desempenho do que os outros escores, mas não com precisão suficiente para prever com segurança a necessidade de ventilação mecânica em pacientes hospitalizados com COVID-19. Novos estudos devem ser realizados para desenvolver escores fáceis de aplicar que tenham melhor calibração e discriminação para auxiliar na difícil decisão de instituir o suporte ventilatório avançado.

Introduction: The COVID-19 pandemic represents a major challenge for health systems around the world, with unprecedented demands on all levels of health care. In primary care, in addition to the care of individuals with flu-like symptoms, the discontinuity of monitoring patients with chronic diseases is a cause of great concern. In hospital care, the immediate need to assist patients with severe and critical forms of COVID-19 required the expansion of conventional and intensive care beds, technological resources for advanced life support and training in record time, as knowledge about the disease evolved. Objectives: The present study has two main objectives. Objective 1: To assess the impact of the COVID-19 pandemic on a cohort of people with hypertension and diabetes in primary care, and to develop and implement a digital solution to improve home monitoring. Objective 2: To assess whether the ABC2-SPH risk score can predict the need for invasive mechanical ventilation (IMV) in patients with COVID-19 and to compare its performance with other scores developed to predict IMV, mortality and other outcomes, including in non-COVID patients. Methods: To achieve objective 1: A multi-methodological study was developed. A quasi-experimental evaluation analyzed the impact of the pandemic on the frequency of consultations and control of patients with hypertension and diabetes in 34 primary health care centers (PHCC) in 10 municipalities in Mucuri Valley (Vale do Mucuri), Minas Gerais, between June 2017 and December 2020, considering March 14, 2020, as the cut-off point, when social restriction measures began. Then, a feasibility study developed an application with a decision support system (DSS) for community health workers (CHW) to identify, during home visits, patients with uncontrolled hypertension and/or diabetes and refer them for in person consultation at the PHCC. A panel of experts evaluated the app's feasibility, usability and usefulness through a specific questionnaire. To achieve objective 2: Retrospective cohort study, derived from the study originally called "Evaluation of the laboratory, radiological and symptomatologic profile of patients infected with the new coronavirus 2019 (SARS-CoV-2) in hospitals in the state of Minas Gerais", which became a multicenter study, carried out in 31 hospitals, in 17 cities in five states The study included patients who were hospitalized in two periods: March to September 2020 and March to December 2021, with a confirmed diagnosis of COVID-19 . In this study, the ABC2-SPH risk score, developed to predict in-hospital mortality from COVID-19, was evaluated for the possibility of predicting the need for mechanical ventilation and compared to other scores: CALL, PREDI-CO, SUM, STSS, COVID_IRS_NLR, CURB-65, SOFA and 4C Mortality Score Results: Objective 1: Of 5070 patients, 4810 (94.9%) had hypertension, 1371 (27.4%) had DM, and 1111 (23.1%) had both diseases. There was a significant reduction in the weekly number of consultations (107, IQR 60.0-153.0 before vs 20.0, IQR 7.0-29.0) after social restriction; P<.001. Only 15.2% (772/5070) of all patients returned for a consultation during the pandemic. Individuals with hypertension had lower systolic (120.0, IQR 120.0-140.0 mm Hg) and diastolic (80.0, IQR 80.0-80.0 mmHg) blood pressure than those who did not return (130.0, IQR 120.0-140.0 mm Hg) and (80.0, IQR 80.0-90.0 mm Hg; P<.001). Also, those who returned had a higher proportion of controlled hypertension (64.3% vs 52.8%). For DM, there were no differences in glycohemoglobin levels. Concerning the DSS, the experts agreed that the CHWs can easily incorporate it into their routines and the app can identify patients at risk and improve treatment. Objective 2: Throughout the study, 4831 patients were included, median age 59.0 (IQR 48.0, 70.0) years-old and 46.3% female. Of those, 34.2 % required intensive care treatment, 26.6% required IMV and 18.7% died. Patients who required IMV had higher prevalence of hypertension, diabetes, obesity, and mortality when compared to those who did not require it (64.3% vs 2.3%, p<0.001). Based on the imputed dataset, the ABC2-SPH AUROC was 0.677 (95% CI 0.681-0.694). Considering only complete cases, the AUROC was 0.70, having the best performance among scores that had larger samples of complete cases. When the data were imputed, was 0.67. Considering only complete cases, the AUROC was 0.70 (95% CI 0.68-0.72, having the best performance among scores that had larger samples of complete cases. Overall, the score discriminations ranged from poor to fair. The SOFA Score had the highest sensitivity, 0.84 (95% CI 0.81-0.86). Conclusions: The COVID-19 pandemic caused a significant drop in the number of consultations of patients with hypertension and diabetes in primary care. An SSD for CHW proved to be feasible and useful for identifying uncontrolled patients at home. ABC2-SPH demonstrated better performance than the other scores, but not accurately enough to reliably predict the need for IMV COVID-19 hospitalized patients. Research should continue to develop easy-to-use scores with better calibration and discrimination, given the importance of assisting clinicians in decision-making when initiating advanced ventilatory support.

Sensibilidade e especificidade de sistemas open access para detecção de interações medicamentosas potenciais / Sensitivity and specificity of open access systems to detect potential drug-drug interactions

Patient safety.Estudo transversal. Objetivo: avaliar a sensibilidade e especificidade de sistemas de rastreamento de acesso aberto para interações medicamentosas potenciais (IMp) em comparação com o DRUG-REAX® system e analisar o impacto clínico potencial das IMp de gravidades "Contraindicada" e "Maior" não detectadas. Métodos: amostra composta por 140 pacientes em acompanhamento em um ambulatório especializado no atendimento a pessoas com doenças crônicas não transmissíveis (DCNT) de um hospital universitário. As IMp foram identificadas e classificadas no DRUG-REAX® System e em oito sistemas de rastreamento de acesso aberto. As IMp de gravidade "Contraindicada" e "Maior" foram analisadas segundo o impacto clínico. Utilizou-se estatística descritiva e calculou-se sensibilidade e especificidade dos sistemas de rastreamento na identificação das IMp. Resultados: Os sistemas de acesso aberto pertencentes as bases Drugs.com, UCLA School of Health e CVC Caremark apresentaram sensibilidade e especificidade > 70%. A totalidade dos sistemas de acesso aberto não detectou os pares ciprofibrato + estatinas e metformina + sitagliptina, cujos impactos clínicos incluíram risco de miopatia e rabdomiólise e hipoglicemia, respectivamente. Cerca de um terço (37,5%) dos sistemas de acesso aberto não detectou a IMp ácido acetilsalicílico + hidroclorotiazida, capaz de ocasionar nefrotoxicidade. Conclusão: A maioria dos pares de IMp integra o rol terapêutico de pacientes com DCNT e cujos impactos clínicos são tempo-dependentes. A combinação de julgamento clínico, revisão periódica do plano terapêutico e os atributos de precisão (sensibilidade e especificidade) são fundamentais para garantir a segurança do paciente, sobretudo no contexto ambulatorial. (AU)

This study aims to evaluate the sensitivity and specificity of open-access screening systems in detecting potential drug-drug interactions (PDDIs) compared to the DRUG-REAX® system and analyze the potential clinical impact of PDDIs of "Contraindicated" and "Major" severities not detected. A cross-sectional study was conducted in an outpatient clinic specialized in caring for patients with noncommunicable diseases (NCDs) of a university hospital. PDDIs were identified and classified in the DRUG-REAX® System and eight open-access screening systems. The "Contraindicated" and "Major" severity PDDIs were analyzed according to clinical impact. Descriptive statistics were used and the sensitivity and specificity of the screening systems were calculated to identify the PDDIs. Results: The open-access systems Drugs.com, UCLA School of Health and CVC Caremark showed sensitivity and specificity > 70%. All open access systems did not detect the pairs ciprofibrate + statins and metformin + sitagliptin, whose clinical impacts included the risk of myopathy/ rhabdomyolysis and hypoglycemia, respectively. About a third (37.5%) of open-access systems did not detect PDDI acetylsalicylic acid + hydrochlorothiazide, which is capable of causing nephrotoxicity. Conclusion: Most pairs of PDDIs are part of the therapeutic role of patients with NCDs and whose clinical impacts are time-dependent. The combination of clinical judgment, periodic review of the therapeutic plan and the attributes of precision (sensitivity and specificity) are essential to ensure patient safety, especially in the outpatient setting. (AU)

Current applications of artificial intelligence for intraoperative decision support in surgery / 医学前沿

Research into medical artificial intelligence (AI) has made significant advances in recent years, including surgical applications. This scoping review investigated AI-based decision support systems targeted at the intraoperative phase of surgery and found a wide range of technological approaches applied across several surgical specialties. Within the twenty-one (n = 21) included papers, three main categories of motivations were identified for developing such technologies: (1) augmenting the information available to surgeons, (2) accelerating intraoperative pathology, and (3) recommending surgical steps. While many of the proposals hold promise for improving patient outcomes, important methodological shortcomings were observed in most of the reviewed papers that made it difficult to assess the clinical significance of the reported performance statistics. Despite limitations, the current state of this field suggests that a number of opportunities exist for future researchers and clinicians to work on AI for surgical decision support with exciting implications for improving surgical care.

Application of artificial intelligence technology: Clinical demands, status and challenges of clinical decision support system for rare diseases / 第二军医大学学报

The incidence of rare diseases is extremely low, but the overall number of patients with rare diseases is quite large. The consequences of rare diseases are severe and impose a heavy burden on patients, their families and the entire society. Although there are many researches on gene sequencing technology and clinical decision support system (CDSS) combined with artificial intelligence technology to assist the diagnosis of rare diseases, the diagnosis of rare diseases remains a great challenge in clinical practice. In this paper, we briefly reviewed the CDSS for rare diseases, aiming to analyze the current technique status and challenges of artificial intelligence technology in rare diseases.

Sistema de apoyo para la toma de decisiones en termografía de glándulas mamarias / Clinical decision support system for decision making in mammary glands thermography

Resumen: Se desarrolló un sistema basado en árboles de decisión con factores de peso heurísticos orientados al diagnóstico mediante termografía mamaria. El sistema de apoyo a la toma de decisiones clínicas propuesto incluye árboles de decisión binarios para la clasificación estadística de algunas patologías de la glándula mamaria. Dentro de ellos, se incluyen factores de peso constantes encontrados a través de la correlación de las variables involucradas en el desarrollo de los padecimientos mamarios de acuerdo al apego estadístico de las características termográficas, así como de la información clínica complementaria (historial clínico, parámetros físicos, carga genética y hábitos, entre otros), con respecto a su incidencia diagnóstica. La certeza del sistema para los trastornos inflamatorios es de 96 %, para mastopatía fibroquística de 78 %, para necrosis grasa de 62 % y para cáncer de seno de 86 %. El 14 % de error se asocia a microcalcificaciones mismas que con la técnica termográfica reportada no es posible diferenciar. Por lo tanto, es posible catalogar el riesgo de una paciente a padecer alguna afección según los resultados arrojados después de llevar a cabo el examen térmico. Con este sistema de apoyo a la decisión se mejora la posibilidad de aplicación de pruebas de detección temprana en la población que sufre de contraindicaciones para realizarse los exámenes con otros métodos, además permite un diagnóstico integral para las demás pacientes.

Abstract: A decision tree based system with heuristic weight factors oriented to diagnosis by thermography was developed. The proposed clinical decision support system (CDSS) includes binary decision trees for statistical classification of some diseases of the mammary gland. These include weight constant factors found by the correlation of the variables involved in the development of breast disorders according to the statistical attachment of the thermal features, as well as complementary clinical information (medical history, physical parameters, genetic load and habits, among others), regarding its diagnostic incidence. The certainty of the system for inflammatory disorders is 96%, for fibrocystic mastopathy is 78 %, for fat necrosis is 62% and for breast cancer is 86%. The 14% error is associated to microcalcifications that with the reported thermographic technique it is not possible to differentiate. Thus, it is possible to catalog the risk of a patient having a condition according to the results obtained after conducting a thermal test. Then, with the CDSS the possibility of applying early detection tests in the population suffering from contraindications to perform the others is improved, in addition it allows a comprehensive diagnosis for other patients.

The influence of body image on surgical decisions in adolescent idiopathic scoliosis patients

OBJECTIVES: The objective of this study was to evaluate whether the severity of deformities in patients with adolescent idiopathic scoliosis contributes to patients’ decision regarding whether to undergo an operation. METHODS: We evaluated body image factors in adolescent idiopathic scoliosis patients. We evaluated the magnitude of the main scoliotic curve, gibbosity (magnitude and location), shoulder height asymmetry and patient’s age. We analyzed the correlation of these data with the number of years the patient was willing to trade for surgery, as measured by the time-trade-off method. RESULTS: A total of 52 patients were studied. We did not find a correlation between any of the parameters that were studied and the number of years that the patient would trade for the surgery. CONCLUSIONS: The magnitude of body deformities in patients with adolescent idiopathic scoliosis does not interfere with the decision to undertake surgical treatment.

Arquétipos openEHR para representação de restrições temporais em diretrizes clínicas / OpenEHR archetypes to represent temporal constraints in clinical guidelines

As Restrições Temporais contidas em diretrizes clínicas representam uma parte fundamental de sua descrição relacionada principalmente aos algoritmos terapêuticos, porém, ainda existe a dificuldade de representar as Restrições Temporais complexas e integrá-las em um Registro Eletrônico de Saúde interoperável. Objetivo: explorar a representação de Restrições Temporais baseando-se em arquétipos da openEHR e Guideline Definition Language. MÉTODO: identificação dos principais tipos de Restrições Temporais existentes, identificação de Restrições Temporais nas diretrizes clínicas de doença renal crônica, fibrilação atrial e mieloma múltiplo, e sua representação em arquétipos e Guideline Definition Language. RESULTADOS: tipos de Restrições Temporais encontrados nas diretrizes clínicas: quantitativo e eventos de repetição (doença renal crônica), quantitativo (fibrilação atrial), quantitativo e qualitativo (mieloma múltiplo). Modelados 4 arquétipos e reutilizado 1 arquétipo da openEHR. CONCLUSÃO: Foi possível representar as Restrições Temporais contidas em diretrizes clínicas em suas diversas classes de eventos baseando-se em arquétipos e Guideline Definition Language da openEHR.

The temporal Constraints contained in clinical practice guidelines represent a fundamental part of their description mainly related to therapeutic algorithms, however, there is still the difficulty of representing the complexTemporal Constraints and integrate them into an Electronic Registration Health Interoperable. OBJECTIVES: To explore the representation of Temporal Constraints based on the openEHR archetypes and Guideline Definition Language. METHODS: identification of the main types of Temporal constraints, identification of Temporal Constraints on clinical guidelines for Chronic Kidney Disease, Atrial Fibrillation and Multiple Myeloma, and its representation in archetypesand Guideline Definition Language. RESULTS: Temporal Constraints types found in practice guidelines in the study:quantitative and repeating events (chronic kidney disease), quantitative (atrial fibrillation), qualitative and quantitative(multiple myeloma). Four archetypes were modeled and 1 archetype openEHR reused. CONCLUSION: It was possible torepresent Temporal Constraints contained in clinical practice guidelines in its various event classes based on archetypes and Guideline Definition Language of openEHR.

Métodos para avaliação de sistemas de apoio à decisão / Methods to evaluate clinical decision-support systems

Os sistemas de apoio a decisão em saúde (SAD) devem ser avaliados abordando vários aspectos, porém definir a metodologia para esta tarefa requer conhecimento dos métodos disponíveis e de como utilizá-los. OBJETIVO: Identificar as principais metodologias para avaliação de SAD, indicando como aplicá-las. MÉTODO: Revisão sistemática no PubMed(maio de 2006 a maio de 2016), incluindo descrição dos principais métodos identificados. Resultados: No aspecto usabilidade,a tendência são metodologias que avaliam a sequência de tarefas, seguidos pelas entrevistas, think-out-loud sessions, questionários e vídeos. A metodologia predominante para avaliação da eficácia foi o ensaio controlado randomizado;na eficiência, a análise de indicadores; na confiabilidade, a comparação dos dados; e na efetividade, as entrevistas, questionários, análise de documentos e estudo de coorte. CONCLUSÃO: Para assegurar a qualidade da avaliação dos SADs propõem-se a integração de diferentes métodos de avaliação abordando diversos aspectos.

The clinical decision-support system (CDSS) should be evaluated considering different aspects, but to define the methodology to this task is necessary to know the available methods and how to use them. Objective: Identify the main methodologies for CDSS evaluation, indicating how to apply them. METHODS: Systematic review on PubMed (May 2006to May 2016), including descriptions of the main methods. RESULTS: Considering the usability aspect, trends are methods to evaluate tasks' sequence, followed by interviews, think-out-loud sessions, questionnaire and videos. Randomized controlledtrial is the major method related to efficacy evaluation; to efficiency, indicator´s analysis; data comparison to reability aspect; and in effectiveness, interview, questionnaires, document analysis and cohort study. CONCLUSION: To ensure CDSS evaluation quality, the proposal is to integrate several evaluation methods integrating deferent aspects.

New Alert Override Codes for the Drug Utilization Review System Derived from Outpatient Prescription Data from a Tertiary Teaching Hospital in Korea / 대한의료정보학회지

OBJECTIVES: This paper proposes new alert override reason codes that are improvements on existing Drug Utilization Review (DUR) codes based on an analysis of DUR alert override cases in a tertiary medical institution. METHODS: Data were obtained from a tertiary teaching hospital covering the period from April 1, 2012 to January 15, 2013. We analyzed cases in which doctors had used the 11 overlapping prescription codes provided by the Health Insurance Review and Assessment Service (HIRA) or had provided free-text reasons. RESULTS: We identified 27,955 alert override cases. Among these, 7,772 (27.8%) utilized the HIRA codes, and 20,183 (72.2%) utilized free-text reasons. According to the free-text content analysis, 8,646 cases (42.8%) could be classified using the 11 HIRA codes, and 11,537 (57.2%) could not. In the unclassifiable cases, we identified the need for codes for "prescription relating to operation" and "emergency situations." Two overlapping prescription codes required removal because they were not used. Codes A, C, F, H, I, and J (for drug non-administration cases) explained surrounding situations in too much detail, making differentiation between them difficult. These 6 codes were merged into code J4: "patient was not taking/will not take the medications involved in the DDI." Of the 11 HIRA codes, 6 were merged into a single code, 2 were removed, and 2 were added, yielding 6 alert override codes. We could codify 23,550 (84.2%) alert override cases using these codes. CONCLUSIONS: These new codes will facilitate the use of the drug-drug interactions alert override in the current DUR system. For further study, an appropriate evaluation should be conducted with prescribing clinicians.

Lifting Shadows off the End-of-Life Care: Hopes and Beliefs on Video Decision Support Tools for Advance Care Planning / 한국호스피스완화의료학회지

As advance care planning is taking center stage in the field of end-of-life care, various tools have been developed to aid in the often emotional and difficult decision-making process. Video decision support tools are one of the most promising means of assistance, of which the modus operandi is to provide more comprehensive and precise information of medical procedures to patients and their families, allowing them to make better informed decisions. Despite such value, some are concerned about its potential negative impact. For example, video footages of some procedures may be shocking and unpalatable to non-medical professionals, and patients and families may refuse the procedures. One approach to soften the sometimes unpleasant visual of medical procedures is to show less aggressive or more relaxing scenes. Yet another potential issue is that the objectivity of video decision support tools might be vulnerable to the very stakeholders who were involved in the development. Some might argue that having multiple stakeholders may function as checks and balances and provide collective wisdom, but we should provide more systematic guarantee on the objectivity of the visual decision aids. Because the decision of the modality of an individual's death is the last and most significant choice in one's life, no party should exert their influence on such a delicate decision. With carefully designed video decision support tools, our patients will live the last moments of their lives with dignity, as they deserve.

Architecture Design of Healthcare Software-as-a-Service Platform for Cloud-Based Clinical Decision Support Service / 대한의료정보학회지

OBJECTIVES: To design a cloud computing-based Healthcare Software-as-a-Service (SaaS) Platform (HSP) for delivering healthcare information services with low cost, high clinical value, and high usability. METHODS: We analyzed the architecture requirements of an HSP, including the interface, business services, cloud SaaS, quality attributes, privacy and security, and multi-lingual capacity. For cloud-based SaaS services, we focused on Clinical Decision Service (CDS) content services, basic functional services, and mobile services. Microsoft's Azure cloud computing for Infrastructure-as-a-Service (IaaS) and Platform-as-a-Service (PaaS) was used. RESULTS: The functional and software views of an HSP were designed in a layered architecture. External systems can be interfaced with the HSP using SOAP and REST/JSON. The multi-tenancy model of the HSP was designed as a shared database, with a separate schema for each tenant through a single application, although healthcare data can be physically located on a cloud or in a hospital, depending on regulations. The CDS services were categorized into rule-based services for medications, alert registration services, and knowledge services. CONCLUSIONS: We expect that cloud-based HSPs will allow small and mid-sized hospitals, in addition to large-sized hospitals, to adopt information infrastructures and health information technology with low system operation and maintenance costs.

Development and application of patient decision aids / 한국역학회지

With the current overdiagnosis of thyroid cancer resulting from routine screening in Korea, it is necessary to educate the public that not all cancers are malignant. The exposure to patient decision aids (PtDAs) compared to usual care reduced the number of people choosing to undergo prostate-specific antigen screening. This article introduces the definition, usefulness, and developmental processes of PtDAs and suggests the urgent need for a Korean PtDA related to thyroid cancer screening.

Electronic Health Records, Electronic Prescribing and Medication Errors: A Systematic Review of Literature, 2000-2014.

Background: The electronic prescribing system, either standalone or embedded in the electronic health record, is a powerful tool in the hands of healthcare providers, as it reduces half of medication errors caused by handwritten prescribing. Objective: This article synthesizes the international literature on electronic health records (EHRs), e-prescribing (EP) and medication errors (MEs) and provides a platform to World Health Organization Eastern Mediterranean Region (WHO-EMR) countries for implementing EHRs and EP in healthcare system. Methods: Computer searches of PubMed, MEDLINE, Quertle®, Google Scholar, Web Knowledge and International Pharmacy Abstract databases were conducted for the years 2000–2014 using several single- and combined-keyword strategies, with 184 articles retained for evaluation. Results: Although e-prescribing integrated with EHR reduces medication errors at all healthcare levels, decreases morbidity and mortality, enhances patient and healthcare provider satisfaction by reducing costs and improving quality of life, it produces different types of medication errors at various stages of the prescription process. An EHR with EP that has a clinical decision support system (CDSS), dose-limit range, drug–drug interaction alert protocols, and formulary decision support helps to improve EP and ensures greater patient safety and other multiple applications. Conclusion: EHRs with EP systems should be implemented in healthcare systems for the sake of better quality healthcare and patient safety throughout the WHO-EMR countries especially in the Kingdom of Saudi Arabia. Evidently there is limited data in these countries and hence further studies are needed to assess impact of EHRs and EP system (EPSs) on medication errors, quality of healthcare, patient safety and outcome, morbidity and mortality rates, patients’ and healthcare providers’ acceptance, and especially its cost-effectiveness.

Differences of Reasons for Alert Overrides on Contraindicated Co-prescriptions by Admitting Department / 대한의료정보학회지

OBJECTIVES: To reveal differences in drug-drug interaction (DDI) alerts and the reasons for alert overrides between admitting departments. METHODS: A retrospective observational study was performed using longitudinal Electronic Health Record (EHR) data and information from an alert and logging system. Adult patients hospitalized in the emergency department (ED) and general ward (GW) during a 46-month period were included. For qualitative analyses, we manually reviewed all reasons for alert overrides, which were recorded as free text in the EHRs. RESULTS: Among 14,780,519 prescriptions, 51,864 had alerts for DDIs (0.35%; 1.32% in the ED and 0.23% in the GW). The alert override rate was higher in the ED (94.0%) than in the GW (57.0%) (p < 0.001). In an analysis of the study population, including ED and GW patients, 'clinically irrelevant alert' (52.0%) was the most common reason for override, followed by 'benefit assessed to be greater than the risk' (31.1%) and 'others' (17.3%). The frequency of alert overrides was highest for anti-inflammatory and anti-rheumatic drugs (89%). In a sub-analysis of the population, 'clinically irrelevant alert' was the most common reason for alert overrides in the ED (69.3%), and 'benefit assessed to be greater than the risk' was the most common reason in the GW (61.4%). CONCLUSIONS: We confirmed that the DDI alerts and the reasons for alert overrides differed by admitting department. Different strategies may be efficient for each admitting department.

Healthcare Decision Support System for Administration of Chronic Diseases / 대한의료정보학회지

OBJECTIVES: A healthcare decision-making support model and rule management system is proposed based on a personalized rule-based intelligent concept, to effectively manage chronic diseases. METHODS: A Web service was built using a standard message transfer protocol for interoperability of personal health records among healthcare institutions. An intelligent decision service is provided that analyzes data using a service-oriented healthcare rule inference function and machine-learning platform; the rules are extensively compiled by physicians through a developmental user interface that enables knowledge base construction, modification, and integration. Further, screening results are visualized for the self-intuitive understanding of personal health status by patients. RESULTS: A recommendation message is output through the Web service by receiving patient information from the hospital information recording system and object attribute values as input factors. The proposed system can verify patient behavior by acting as an intellectualized backbone of chronic diseases management; further, it supports self-management and scheduling of screening. CONCLUSIONS: Chronic patients can continuously receive active recommendations related to their healthcare through the rule management system, and they can model the system by acting as decision makers in diseases management; secondary diseases can be prevented and health management can be performed by reference to patient-specific lifestyle guidelines.

Investigation of Data Representation Issues in Computerizing Clinical Practice Guidelines in China / 대한의료정보학회지

OBJECTIVES: From the point of view of clinical data representation, this study attempted to identify obstacles in translating clinical narrative guidelines into computer interpretable format and integrating the guidelines with data in Electronic Health Records in China. METHODS: Based on SAGE and K4CARE formulism, a Chinese clinical practice guideline for hypertension was modeled in Protege by building an ontology that had three components: flowchart, node, and vMR. Meanwhile, data items imperative in Electronic Health Records for patients with hypertension were reviewed and compared with those from the ontology so as to identify conflicts and gaps between. RESULTS: A set of flowcharts was built. A flowchart comprises three kinds of node: State, Decision, and Act, each has a set of attributes, including data input/output that exports data items, which then were specified following ClinicalStatement of HL7 vMR. A total of 140 data items were extracted from the ontology. In modeling the guideline, some narratives were found too inexplicit to formulate, and encoding data was quite difficult. Additionally, it was found in the healthcare records that there were 8 data items left out, and 10 data items defined differently compared to the extracted data items. CONCLUSIONS: The obstacles in modeling a clinical guideline and integrating with data in Electronic Health Records include narrative ambiguity of the guideline, gaps and inconsistencies in representing some data items between the guideline and the patient' records, and unavailability of a unified medical coding system. Therefore, collaborations among various participants in developing guidelines and Electronic Health Record specifications is needed in China.

Expert System Shells for Rapid Clinical Decision Support Module Development: An ESTA Demonstration of a Simple Rule-Based System for the Diagnosis of Vaginal Discharge / 대한의료정보학회지

OBJECTIVES: This study demonstrates the feasibility of using expert system shells for rapid clinical decision support module development. METHODS: A readily available expert system shell was used to build a simple rule-based system for the crude diagnosis of vaginal discharge. Pictures and 'canned text explanations' are extensively used throughout the program to enhance its intuitiveness and educational dimension. All the steps involved in developing the system are documented. RESULTS: The system runs under Microsoft Windows and is available as a free download at http://healthcybermap.org/vagdisch.zip (the distribution archive includes both the program's executable and the commented knowledge base source as a text document). The limitations of the demonstration system, such as the lack of provisions for assessing uncertainty or various degrees of severity of a sign or symptom, are discussed in detail. Ways of improving the system, such as porting it to the Web and packaging it as an app for smartphones and tablets, are also presented. CONCLUSIONS: An easy-to-use expert system shell enables clinicians to rapidly become their own 'knowledge engineers' and develop concise evidence-based decision support modules of simple to moderate complexity, targeting clinical practitioners, medical and nursing students, as well as patients, their lay carers and the general public (where appropriate). In the spirit of the social Web, it is hoped that an online repository can be created to peer review, share and re-use knowledge base modules covering various clinical problems and algorithms, as a service to the clinical community.