A Conceptual Framework to Study the Implementation of Clinical Decision Support Systems (BEAR): Literature Review and Concept Mapping.

BACKGROUND: The implementation of clinical decision support systems (CDSSs) as an intervention to foster clinical practice change is affected by many factors. Key factors include those associated with behavioral change and those associated with technology acceptance. However, the literature regarding these subjects is fragmented and originates from two traditionally separate disciplines: implementation science and technology acceptance. OBJECTIVE: Our objective is to propose an integrated framework that bridges the gap between the behavioral change and technology acceptance aspects of the implementation of CDSSs. METHODS: We employed an iterative process to map constructs from four contributing frameworks-the Theoretical Domains Framework (TDF); the Consolidated Framework for Implementation Research (CFIR); the Human, Organization, and Technology-fit framework (HOT-fit); and the Unified Theory of Acceptance and Use of Technology (UTAUT)-and the findings of 10 literature reviews, identified through a systematic review of reviews approach. RESULTS: The resulting framework comprises 22 domains: agreement with the decision algorithm; attitudes; behavioral regulation; beliefs about capabilities; beliefs about consequences; contingencies; demographic characteristics; effort expectancy; emotions; environmental context and resources; goals; intentions; intervention characteristics; knowledge; memory, attention, and decision processes; patient-health professional relationship; patient's preferences; performance expectancy; role and identity; skills, ability, and competence; social influences; and system quality. We demonstrate the use of the framework providing examples from two research projects. CONCLUSIONS: We proposed BEAR (BEhavior and Acceptance fRamework), an integrated framework that bridges the gap between behavioral change and technology acceptance, thereby widening the view established by current models.

Neuromyelitis optica spectrum disorder in pediatrics. case report

ABSTRACT Introduction: Neuromyelitis optica is an inflammatory disorder of the central nervous system that accounts for 5% of demyelinating diseases in pediatrics. Its clinical presentation is variable and associated to the involved area of the central nervous system. Case presentation: This is the case of a 15-year-old patient who consulted several times for nonspecific neurological symptoms. During his last visit to the Clínica Universitaria Colombia in Bogotá, he presented with bilateral optic neuritis, associated with frontal and parietal headache. Immunophenotyping studies were carried out, reporting positive IgG anti-aquaporin 4 antibodies (anti-AQP4 antibody), thus leading to a diagnosis of seropositive neuromyelitis optica spectrum disorder (NMOSD). Management with methylprednisolone pulses was initiated with subsequent outpatient management with rituximab that allowed stabilizing the disease. Discussion: This is an interesting case due to its insidious and uncertain onset in a pediatric patient. It was possible to evaluate clinical and diagnostic differences in relation to its presentation in adults. NMOSD mediated by anti-AQP4 is rare; brain and bone marrow MRI are essential for diagnosis. The treatment of choice for acute conditions consists of high doses of methylprednisolone. Conclusion: This disorder may result in irreversible neurological damage; for this reason, high suspicion is required for early diagnosis and timely treatment.

RESUMEN Introducción. La neuromielitis óptica es un trastorno inflamatorio del sistema nervioso central que representa el 5% de las enfermedades desmielinizantes en pediatría. Su presentación clínica es variable y está ligada al área del sistema nervioso central comprometida. Presentación de caso. Paciente masculino de 15 años quien consulta en varias oportunidades por síntomas neurológicos inespecíficos y que en su última visita a la Clínica Universitaria Colombia, en Bogotá, presenta un cuadro de neuritis óptica bilateral, asociado a cefalea frontal y parietal. Se realizan estudios de in-munotipificación que documentan positividad para anticuerpos IgG y anti acuaporina 4 (ACS anti-AQP4), permitiendo así el diagnóstico de desorden del espectro de neuromielitis óptica (NMOSD, por su sigla en inglés) seropositivo; se inicia manejo con pulsos de metilprednisolona a dosis de 1g intravenoso cada 24 horas, con posterior manejo ambulatorio con Rituximab, que permiten estabilización de la enfermedad. Discusión. Se presenta un caso interesante por su inicio insidioso e incierto en un paciente pediátrico. Este caso permite evaluar las diferencias clínicas y diagnósticas en relación a su presentación en adultos. El NMOSD mediado por ACS anti-AQP4 es poco común; para su diagnóstico es esencial la resonancia magnética cerebral y de médula ósea. El tratamiento de elección para cuadros agudos consiste en altas dosis de metilprednisolona. Conclusión. El NMOSD puede producir daño neurológico irreversible, por esto requiere un alto índice de sospecha para su diagnóstico temprano y tratamiento oportuno.

Multiple Hereditary Exostoses: Report of an EXT2 Gene Mutation in a Colombian Family.

Multiple hereditary exostoses (MHE) is a rare disease with autosomal dominant inheritance, caused by heterozygous germline mutations in the EXT1 or EXT2 genes. This disorder is characterized by the growth of prominences surrounded by cartilage in the growth plates and the long bones. Here, we report a family affected by MHE. In this family, a pathogenic variant c.544C > T (p. Arg182Ter) was identified in the EXT2 gene. This variant has been previously described in the literature, and here we are reporting the relationship with clinical findings. MHE is suspected according to the clinical manifestations; molecular research should be performed to establish the most frequent mutations. A support, diagnosis, and follow-up group should be created, and genetic counseling should be available for patients and families.

Comparing a Mobile Decision Support System Versus the Use of Printed Materials for the Implementation of an Evidence-Based Recommendation: Protocol for a Qualitative Evaluation.

BACKGROUND: The distribution of printed materials is the most frequently used strategy to disseminate and implement clinical practice guidelines, although several studies have shown that the effectiveness of this approach is modest at best. Nevertheless, there is insufficient evidence to support the use of other strategies. Recent research has shown that the use of computerized decision support presents a promising approach to address some aspects of this problem. OBJECTIVE: The aim of this study is to provide qualitative evidence on the potential effect of mobile decision support systems to facilitate the implementation of evidence-based recommendations included in clinical practice guidelines. METHODS: We will conduct a qualitative study with two arms to compare the experience of primary care physicians while they try to implement an evidence-based recommendation in their clinical practice. In the first arm, we will provide participants with a printout of the guideline article containing the recommendation, while in the second arm, we will provide participants with a mobile app developed after formalizing the recommendation text into a clinical algorithm. Data will be collected using semistructured and open interviews to explore aspects of behavioral change and technology acceptance involved in the implementation process. The analysis will be comprised of two phases. During the first phase, we will conduct a template analysis to identify barriers and facilitators in each scenario. Then, during the second phase, we will contrast the findings from each arm to propose hypotheses about the potential impact of the system. RESULTS: We have formalized the narrative in the recommendation into a clinical algorithm and have developed a mobile app. Data collection is expected to occur during 2018, with the first phase of analysis running in parallel. The second phase is scheduled to conclude in July 2019. CONCLUSIONS: Our study will further the understanding of the role of mobile decision support systems in the implementation of clinical practice guidelines. Furthermore, we will provide qualitative evidence to aid decisions made by low- and middle-income countries' ministries of health about investments in these technologies.

[Design and Implementation of the Data Collection Tools for National Mental Health Survey of Colombia, 2015]. / Diseño e implementación de los instrumentos de recolección de la Encuesta Nacional de Salud Mental Colombia 2015.

INTRODUCTION: Population surveys on mental health are performed as part of the inputs required for the creation, implementation and evaluation of policies related to mental health, worldwide, and as an initiative of the World Health Organisation (WHO). was held The fourth National Survey of Mental Health (ENSM 2015) was carried out during the first half of 2015 on a representative sample of 2,727 children between 7 and 11 years of age, 1,754 adolescents, and 10, 870 adults who were selected throughout the country. OBJECTIVE: To describe the selection and definition of the tools used to measure mental health (including social cognition and violence), problems, mental disorders, and the evaluation of health states, as well as to describe the process used to develop the data collection tools finally used. RESULTS: The measurement of mental disorders in children was performed using the Diagnostic Interview Schedule for Children (DISC), and the Composite International Diagnostic Interview (CIDI) was used for adolescents and adults. For the remaining components evaluated in the survey, a search was conducted on the tools used at a national and international level. The selection of the toos used for the evaluation was based on the questions made by each tool, as well as the scientific validity that could be obtained from the results. In some cases the complete tool (as published) was used, in other cases the tools were constructed unifying parts of different ones, or questions were written based on the concepts or characteristics to be measured. Subsequently, a validation of content, concept and semantic of every tool was carried out, including the CIDI and DISC. The resulting tools were used on a group of people with different characteristics. It was noted that further clarification was necessary for some people to fully understand what was being asked. Because the collection of all the information in the survey would be computer assisted, a stream format was generated to guide the implementation in Blaise software, after the creation and wording of each tool in order to review the validation process of the survey and to ensure the integrity in the order of questions and their format. Fictitious cases were generated during the process, and volunteers participated in the testing. CONCLUSIONS: The tools for information collection used in the National Survey of Mental Health 2015 are presented.

Diseño e implementación de los instrumentos de recolección de la Encuesta Nacional de Salud Mental Colombia 2015 / Design and Implementation of the Data Collection Tools for National Mental Health Survey of Colombia, 2015

Introducción: Como parte de los insumos necesarios para la creación, la implementación y la evaluación de políticas relacionadas con la salud mental, en todo el mundo y como iniciativa de la Organización Mundial de la Salud, se llevan a cabo encuestas poblacionales relacionadas con el tema. Durante el primer semestre de 2015, se llevó a cabo la cuarta Encuesta Nacional de Salud Mental (ENSM 2015), con una muestra de 2.727 niños entre 7 y 12 años, 1.754 adolescentes y 10.870 adultos seleccionados de diferentes lugares del país. Objetivos: Describir la selección y definición de los instrumentos que utilizar para la medición de la salud mental (incluyendo cognición social y violencias), los problemas, los trastornos mentales y la valoración de estados de salud, así como los mecanismos empleados para derivar en el instrumento final de recolección. Resultados: La medición de trastornos mentales en niños se realizó utilizando el Diagnostic Interview Schedule for Children (DISC), y para adolescentes y adultos se utilizó el Composite International Diagnostic Interview (CIDI). Para los demás componentes evaluados en la ENSM 2015, se realizó una búsqueda de los instrumentos utilizados dentro y fuera de Colombia. La selección de los instrumentos utilizados para la evaluación se basó en las preguntas de cada instrumento, así como la validez científica que se podría obtener en los resultados. En algunos casos se utilizó el instrumento completo (como fue validado), se construyó uno nuevo uniendo partes de diferentes instrumentos o se redactaron las preguntas partiendo de los conceptos o características que se va a medir. Se realizó una validación de contenido, de concepto y de semántica de todos los instrumentos, incluyendo CIDI y DISC. Los instrumentos resultantes se aplicaron a un grupo de sujetos de diferentes características y se detectaron algunas aclaraciones necesarias para la comprensión de algunas preguntas. Dado que la recolección de la información en la encuesta sería totalmente en formato electrónico, tras la construcción y la redacción de cada instrumento, se generó un formato de flujo para orientar la implementación del formato en el software Blaise. Luego de la implementación, tuvo lugar un proceso de validación de la encuesta implementada para garantizar la integridad en el orden de las preguntas y los saltos. Para este proceso se generaron casos ficticios y también se contó con la participación de voluntarios para realizar las pruebas. Conclusiones: Se presentan los apartes del instrumento utilizado en la ENSM 2015.

Introduction: Population surveys on mental health are performed as part of the inputs required for the creation, implementation and evaluation of policies related to mental health, worldwide, and as an initiative of theWorld Health Organisation (WHO).was held The fourth National Survey of Mental Health (ENSM 2015)was carried out during the first half of 2015 on a representative sample of 2,727 children between 7 and 11 years of age, 1,754 adolescents, and 10, 870 adults who were selected throughout the country. Objective: To describe the selection and definition of the tools used to measure mental health (including social cognition and violence), problems, mental disorders, and the evaluation of health states, as well as to describe the process used to develop the data collection tools finally used. Results: The measurement of mental disorders in children was performed using the Diagnostic Interview Schedule for Children (DISC), and the Composite International Diagnostic Interview(CIDI)was used for adolescents and adults. For the remaining components evaluated in the survey, a search was conducted on the tools used at a national and international level. The selection of the toos used for the evaluation was based on the questions made by each tool, as well as the scientific validity that could be obtained from the results. In some cases the complete tool (as published) was used, in other cases the tools were constructed unifying parts of different ones, or questions were written based on the concepts or characteristics to be measured. Subsequently, a validation of content, concept and semantic of every tool was carried out, including the CIDI and DISC. The resulting tools were used on a group of people with different characteristics. It was noted that further clarification was necessary for some people to fully understand what was being asked. Because the collection of all the information in the survey would be computer assisted, a stream format was generated to guide the implementation in Blaise software, after the creation and wording of each tool in order to review the validation process of the survey and to ensure the integrity in the order of questions and their format. Fictitious cases were generated during the process, and volunteers participated in the testing. Conclusions: The tools for information collection used in the National Survey of Mental Health 2015 are presented.

Valor pronóstico de la biopsia renal preimplante en donantes fallecidos de edad avanzada en la función renal al año del trasplante / Prognostic utility of preimplantation kidney biopsy from deceased older donors in first year post-transplant renal function

Antecedentes: La biopsia renal preimplante puede aportar información útil evolutiva postrasplante. Objetivo: Analizar el valor pronóstico de la biopsia renal de donantes de edad avanzada respecto al filtrado glomerular estimado MDRD-4 (FGe) al año del trasplante. Métodos: Estudiamos a 124 receptores de trasplante renal de donantes fallecidos de ≥60 años, con biopsia renal preimplante. Los trasplantes fueron realizados en nuestro centro, entre marzo del 2008 y mayo del 2012. Las biopsias se valoraron según el baremo propuesto por O’Valle et al. y se categorizaron en 3 grupos: 0-3, 4-5, 6-8 puntos. Se descartaron los riñones con una puntuación >8. El 77% de los donantes tenía ≥70 años. Resultados: El FGe medio (DE) del grupo 6-8 al año del trasplante: 38,5 (14,1) mL/min/1,73m2 fue menor que el del grupo 4-5: 46,3 (15,7) (p=0,03) y del grupo 0-3: 49,6 (12,5) (p=0,04). Se registraron 7 (19%) pacientes con FGe<30mL/min/1,73m2 en el grupo 6-8 vs. 8 (14%) en el grupo 4-5 y ninguno en el grupo 0-3 (p=0,17). En el análisis de regresión logística, OR (IC 95%), que valoró los pacientes con FGe<30mL/min/1,73m2 al año del trasplante, la función retrasada del injerto (6,3 [1,9-21,3]) y el rechazo agudo (5,8 [1,1-31]) fueron significativos. La puntuación del daño histológico de las biopsias, grupo 6-8 vs. 0-5, presentó un OR ajustado no significativo de 2,2 (0,7-7,3). Conclusiones: Los riñones con mayor afectación histológica presentaron un menor FGe al año del trasplante. La función renal retrasada del injerto y el rechazo fueron factores de riesgo significativos de un bajo FGe al año del trasplante (AU)

Background: Preimplantation renal biopsy provides potentially valuable information about post-transplant renal function. Objective: To assess the prognostic value of preimplantation kidney biopsy from older donors in determining 1-year post-transplant estimated glomerular filtration rate MDRD-4 (eGFR). Methods: We evaluated a cohort of 124 renal transplant recipients from deceased donors ≥60 years old, performed at our center between March 2008 and May 2012. Biopsies were assessed by applying the score proposed by O’Valle et al. The overall score was stratified into 3 levels: 0-3, 4-5 and 6-8 points. Kidneys scoring > 8 points were discarded. A total of 77% of the donors were ≥70 years. Results: One year post-transplant, mean eGFR (SD) was lower in transplant recipients with 6-8 points (38.5 [14.1] mL/min/1.73m2) than in the group scoring 4-5 points (46.3 [15.7] [p=0.03]) and the group scoring 0-3 (49.6 [12.5] [P=.04]). Seven patients (19%) had eGFR <30mL/min/1.73m2 1 year post-transplant in group 6-8 vs. 8 (14%) in group 4-5 and none in group 0-3. In the logistic regression, OR (95% IC), to determine patients with 1-year post-transplant eGFR (<30mL/min/1.73m2), delayed graft function (6.3 [1.9-21.3]) and acute rejection (5.8 [1.1-31]), were significant. The adjusted OR of biopsy score group 6-8 vs. 0-5, was 2.2 (0.7-7.3). Conclusions: Allografts with higher pathologic score in preimplantation renal biopsy were associated with a worse 1-year post-transplant eGFR. Delayed graft function and acute rejection were significant risk factors for 1-year post-transplant low eGFR (AU)

Prognostic utility of preimplantation kidney biopsy from deceased older donors in first year post-transplant renal function.

BACKGROUND: Preimplantation renal biopsy provides potentially valuable information about post-transplant renal function. OBJECTIVE: To assess the prognostic value of preimplantation kidney biopsy from older donors in determining 1-year post-transplant estimated glomerular filtration rate MDRD-4 (eGFR). METHODS: We evaluated a cohort of 124 renal transplant recipients from deceased donors ≥60 years old, performed at our center between March 2008 and May 2012. Biopsies were assessed by applying the score proposed by O'Valle et al. The overall score was stratified into 3 levels: 0-3, 4-5 and 6-8 points. Kidneys scoring > 8 points were discarded. A total of 77% of the donors were ≥70 years. RESULTS: One year post-transplant, mean eGFR (SD) was lower in transplant recipients with 6-8 points (38.5 [14.1] mL/min/1.73m(2)) than in the group scoring 4-5 points (46.3 [15.7] [p=0.03]) and the group scoring 0-3 (49.6 [12.5] [P=.04]). Seven patients (19%) had eGFR <30mL/min/1.73m(2) 1 year post-transplant in group 6-8 vs. 8 (14%) in group 4-5 and none in group 0-3. In the logistic regression, OR (95% IC), to determine patients with 1-year post-transplant eGFR (<30mL/min/1.73m(2)), delayed graft function (6.3 [1.9-21.3]) and acute rejection (5.8 [1.1-31]), were significant. The adjusted OR of biopsy score group 6-8 vs. 0-5, was 2.2 (0.7-7.3). CONCLUSIONS: Allografts with higher pathologic score in preimplantation renal biopsy were associated with a worse 1-year post-transplant eGFR. Delayed graft function and acute rejection were significant risk factors for 1-year post-transplant low eGFR.

Manejo médico del onfalocele gigante con sulfadiazina de plata tópica / Initial nonoperative management of giant omphalocele using topical silver sulfadiazine

El onfalocele es un defecto congénito de la pared abdominal, de presentación infrecuente, que puede asociarse con otro tipo de malformaciones genéticas. El manejo es quirúrgico y consiste en la reducción de las vísceras herniadas para cerrar la fascia y la piel, aunque el onfalocele gigante representa un problema mayor debido al tamaño del defecto, por lo cual el cierre primario con frecuencia debe diferirse. Se presenta un recién nacido con diagnóstico prenatal de onfalocele gigante a quien se realiza manejo médico con sulfadiazina de plata para epitelizar el saco con adecuado éxito, logrando diferir el manejo quirúrgico...

Omphalocele is a rare birth defect of the abdominal wall which may be associated to other genetic abnormalities. It is managed surgically by reducing the herniated organs followed by closure of the fascia and skin. However, giant omphalocele represents a greater problem due to the size of the defect, for which the final closure must be delayed. We present an infant with a prenatal diagnosis of giant omphalocele initially treated with silver sulfadiazine coverage allowing epithelialization of the sac constituting a bridge to delayed surgical closure...

El procesamiento de lenguaje natural y su relación con la investigación en salud mental / The Natural Language Process and Its Relationship With Mental Health Research

Uno de los principales motivos para la introducción de computadores en ambientes clínicos fue la posibilidad de compilar y analizar los grandes volúmenes de información consignados en las historias clínicas. A través de la introducción de esta tecnología, se buscó responder a preguntas aparentemente sencillas como: ¿qué pacientes presentaron determinada condición?, ¿qué clase de ayudas diagnósticas se utilizaron para detectar la condición?, ¿cuáles fueron los resultados de las pruebas realizadas? o ¿cuál fue el tratamiento instaurado? Han pasado varias décadas desde que los computadores entraron a los hospitales, y son innegables los avances en los sistemas de información clínica. Sin embargo, en muchos casos a ún es difícil responder a estas preguntas confiablemente.

One of the main reasons for the introduction of computers in clinical settings was the possibility of compiling and analyzing the large volumes of information contained in medical records. Through the introduction of this technology, the aim was to answer seemingly simple questions such as: which patients presented a certain condition, what kind of diagnostic aids were used to detect the condition, what were the results of the tests performed, or what was the treatment given? Several decades have passed since computers entered hospitals, and the advances in clinical information systems are undeniable. However, in many cases it is still difficult to answer these questions reliably.

Octreotide en quilotórax secundario a corrección de hernia diafragmática congénita / Octreotide for treatment of chylothorax after repair of congenital diaphragmatic hernia

La presencia de quilo en la cavidad pleural es una situación rara cuya causa puede ser adquirida (trauma quirúrgico) o congénita (anomalías del sistema linfático), con manifestaciones clínicas variables dependientes de la cantidad y pérdida de quilo (desnutrición, alteración hidroelectrolítica e inmunosupresión). Se presenta una recién nacida con diagnóstico prenatal de hernia diafragmática izquierda con quilotórax de etiología traumática, a quien se realiza tratamiento médico mediante soporte nutricional y octreotide, con resolución y sin necesidad de optar por manejo quirúrgico...

Chyle effusion in the pleural cavity is a rare situation. It may be acquired (surgical injuries) or congenital (abnormalities of the lymphatic system). Clinical manifestations are varied and depend on the amount of chyle loss (malnutrition, fluid and electrolyte imbalance and immune suppression). This article reports the case of a female newborn infant diagnosed with left diaphragmatic hernia who presented postoperative chylothorax. Medical management included nutritional support and octreotide. Resolution of chylothorax was obtained with no additional surgical treatment...