Assessment of the Quality of Current American Dental Association Clinical Practice Guidelines.

INTRODUCTION: The American Dental Association (ADA) defines evidence-based dentistry (EBD) as "an approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences." Clinical practice guidelines (CPGs) are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. Therefore, ADA CPGs are the most rigorous examples of EBD to inform clinical practice. CPGs should be of the highest level of quality to ensure the appropriateness and timeliness of clinical recommendations. OBJECTIVES: The aim of this study was to measure the methodological rigor and transparency of the ADA CPGs. METHODS: Each ADA CPG was appraised by 4 independent assessors using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Quantitative quality scores were obtained for 6 domains and overall quality. In addition, assessors provided a qualitative analysis by providing comments for each item and an appraisal of the full recommendation. RESULTS: A quality score of 75% was used as the threshold for high-quality guidelines. Using this metric, 6 of the current 10 current ADA CPGs were considered to be of high quality, 1 was slightly below the quality threshold, and 3 were considered marginal. Even among those evaluated to be high quality in overall assessment, certain domains did not reach the quality threshold of 75%. CONCLUSION: Overall, the ADA CPGs collectively provide high-quality guidance for the clinician. While the AGREE appraisal guidelines have been used in CPG development since 2016, there is still room for improvement in certain domains (i.e., stakeholder involvement, rigor of development, applicability, and editorial independence). KNOWLEDGE TRANSFER STATEMENT: The results of this study summarize the methodological rigor and transparency of the 10 current ADA clinical practice guidelines. Since adoption of AGREE standards (2016), CPGs have been uniformly of high quality. The quality of older CPGs was somewhat lower but overall deemed acceptable. Thus, ADA CPGs may be used with confidence to inform practitioners of treatment options supported by rigorous evidence-based dentistry standards. However, there is still room for improvement in methodological quality.

A Standards-Based Architecture Proposal for Integrating Patient mHealth Apps to Electronic Health Record Systems.

BACKGROUND: Mobile health Applications (mHealth Apps) are opening the way to patients' responsible and active involvement with their own healthcare management. However, apart from Apps allowing patient's access to their electronic health records (EHRs), mHealth Apps are currently developed as dedicated "island systems". OBJECTIVE: Although much work has been done on patient's access to EHRs, transfer of information from mHealth Apps to EHR systems is still low. This study proposes a standards-based architecture that can be adopted by mHealth Apps to exchange information with EHRs to support better quality of care. METHODS: Following the definition of requirements for the EHR/mHealth App information exchange recently proposed, and after reviewing current standards, we designed the architecture for EHR/mHealth App integration. Then, as a case study, we modeled a system based on the proposed architecture aimed to support home monitoring for congestive heart failure patients. We simulated such process using, on the EHR side, OpenMRS, an open source longitudinal EHR and, on the mHealth App side, the iOS platform. RESULTS: The integration architecture was based on the bi-directional exchange of standard documents (clinical document architecture rel2 - CDA2). In the process, the clinician "prescribes" the home monitoring procedures by creating a CDA2 prescription in the EHR that is sent, encrypted and de-identified, to the mHealth App to create the monitoring calendar. At the scheduled time, the App alerts the patient to start the monitoring. After the measurements are done, the App generates a structured CDA2-compliant monitoring report and sends it to the EHR, thus avoiding local storage. CONCLUSIONS: The proposed architecture, even if validated only in a simulation environment, represents a step forward in the integration of personal mHealth Apps into the larger health-IT ecosystem, allowing the bi-directional data exchange between patients and healthcare professionals, supporting the patient's engagement in self-management and self-care.

Do language fluency and other socioeconomic factors influence the use of PubMed and MedlinePlus?

BACKGROUND: Increased usage of MedlinePlus by Spanish-speakers was observed after introduction of MedlinePlus in Spanish. This probably reflects increased usage of MEDLINE and PubMed by those with greater fluency in the language in which it is presented; but this has never been demonstrated in English speakers. Evidence that lack of English fluency deters international healthcare personnel from using PubMed could support the use of multi-language search tools like Babel-MeSH. OBJECTIVES: This study aims to measure the effects of language fluency and other socioeconomic factors on PubMed MEDLINE and MedlinePlus access by international users. METHODS: We retrospectively reviewed server pageviews of PubMed and MedlinePlus from various periods of time, and analyzed them against country statistics on language fluency, GDP, literacy rate, Internet usage, medical schools, and physicians per capita, to determine whether they were associated. RESULTS: We found fluency in English to be positively associated with pageviews of PubMed and MedlinePlus in countries with high literacy rates. Spanish was generally found to be positively associated with pageviews of MedlinePlus en Español. The other parameters also showed varying degrees of association with pageviews. CONCLUSIONS: After adjusting for the other factors investigated in this study, language fluency was a consistently significant predictor of the use of PubMed, MedlinePlus English and MedlinePlus en Español. This study may support the need for multi-language search tools and may increase access of health information resources from non-English speaking countries.

Usability of selected databases for low-resource clinical decision support.

BACKGROUND: Smartphones are increasingly important for clinical decision support, but smartphone and Internet use are limited by cost or coverage in many settings. txt2MEDLINE provides access to published medical evidence by text messaging. Previous studies have evaluated this approach, but we found no comparisons with other tools in this format. OBJECTIVES: To compare txt2MEDLINE with other databases for answering clinical queries by text messaging in low-resource settings. METHODS: Using varied formats, we searched txt2MEDLINE and five other search portals (askMEDLINE, Cochrane, DynaMed, PubMed PICO, and UpToDate) to develop optimal strategies for each. We then searched each database again with five benchmark queries, using the customized search-optimization formats. We truncated the results to less than 480 characters each to simulate delivering them to a maximum of three text messages. Clinicians with practice experience in low-resource areas scored the results on a 5-point Likert scale. RESULTS: Median scores and standard deviations from 17 reviewers were: txt2M2MEDLINE, 3.2±0.82 (control); askMEDLINE, 3.2±0.90 (p = 0.918); Cochrane, 3.8±0.58 (p = 0.073); DynaMed, 3.6±0.65 (p = 0.105); PubMed PICO, 3.6±0.82 (p = 0.005); and UpToDate, 4.0±0.52 (p = 0.002). Our sample size was sufficiently powered to find differences of 1.0 point. CONCLUSIONS: Comparing several possible sources for texting-based clinical-decision-support information, our results did not demonstrate one-point differences in usefulness on a scale of 1 to 5. PubMed PICO and UpToDate were significantly better than txt2MEDLINE, but with relatively small improvements in Likert score (0.4 and 0.8, respectively). In a texting-only setting, txt2MEDLINE is comparable to simulated alternatives based on established reference sources.

Effect of image compression on telepathology. A randomized clinical trial.

CONTEXT: For practitioners deploying store-and-forward telepathology systems, optimization methods such as image compression need to be studied. OBJECTIVE: To determine if Joint Photographic Expert Group (JPG or JPEG) compression, a glossy image compression algorithm, negatively affects the accuracy of diagnosis in telepathology. DESIGN: Double-blind, randomized, controlled trial. SETTING: University-based pathology departments. PARTICIPANTS: Resident and staff pathologists at the University of Illinois, Chicago, and University of Cincinnati, Cincinnati, Ohio. INTERVENTION: Compression of raw images using the JPEG algorithm. MAIN OUTCOME MEASURES: Image acceptability, accuracy of diagnosis, confidence level of pathologist, image quality. RESULTS: There was no statistically significant difference in the diagnostic accuracy between noncompressed (bit map) and compressed (JPG) images. There were also no differences in the acceptability, confidence level, and perception of image quality. Additionally, rater experience did not significantly correlate with degree of accuracy. CONCLUSIONS: For providers practicing telepathology, JPG image compression does not negatively affect the accuracy and confidence level of diagnosis. The acceptability and quality of images were also not affected.

Telemedicine and telepathology at the Armed Forces Institute of Pathology: history and current mission.

The Armed Forces Institute of Pathology uses telepathology and telemedicine programs to support its mission of providing pathology consultation, education, and research. The telepathology service is based on a static imaging or "store-and-forward" approach using both proprietary equipment and open systems through the Internet. Initiated in 1993, the service provides rapid expert consultation to pathologists globally. Diagnoses are provided by pathologists in 22 specialized departments. Educational programs are delivered through the World Wide Web. Category I continuing medical education credits can be obtained through Internet-based courses. Research activities are focused on forensic applications and the creation of image databases.

[Long-term follow-up study of 35 children with ADS treated with zidovudine (AZT)]. / Estudio evolutivo de 35 niños afectos de síndrome de inmunodeficiencia adquirida (SIDA) en tratamiento con Zidovudina (AZT).

Thirty-five children diagnosed of AIDS were studied in order to evaluate toxicity and efficacy of oral Zidovudine treatment (AZT), as well as to analyze the clinical, biochemical, immunological and virological evolution of HIV infection throughout the treatment. Patients (19 males and 16 females) were studied from April 1988 to May 1990 with a mean follow-up time of 13.5 months (SD = 6.7 months). The mean age of the group was 4.68 years. The means of acquisition of this disease was 71.45 vertical and 28.6% via hemo-derivatives. Tolerance has been good with the main toxicity being hematological (28.5% anemia and/or neutropenia), 23% of which required blood supplements. The presence of neurological involvement and thrombopenia were observed in the incidence of greater toxicity. No influence on weight during AXT treatment was observed and hepatosplenomegalia and adenopathies were not modified. Bacterial and opportunistic infections were observed in 97.1% and 20% of patients, respectively. Neurological evolution was irregular and the improvement observed in some patients was mild and transitory. Three patients died during the follow-up from intercurrent infectious process. A progressive increase in MCV and a tendency towards leucopenia and lymphopenia (mainly in hemo-derivative infected patients) was observed. Neither significant immunological nor virological changes were observed during the treatment (except the tendency to diminish basal hypergammaglobulinemia). The results of this study were compared to other pediatric series treated with AZT.

A competitive displacement assay to detect saxitoxin and tetrodotoxin.

An assay is described which detects saxitoxin (STX) and tetrodotoxin (TTX) by their competitive displacement of [3H]saxitoxin from its receptor in rat brain membranes. The assay has a sensitivity of 0.15 ng STX/ml and 0.8 ng TTX/ml for buffer samples. The assay was also applied to detection of these toxins in unextracted human plasma and found to have a sensitivity of 0.5 ng STX/ml and 0.6 ng TTX/ml. The competitive displacement assay appears to be the most sensitive procedure yet for detection of STX and TTX.

Detection of T-2 toxin by an improved radioimmunoassay.

T-2 toxin in serum, urine, and saline was analyzed by a modified radioimmunoassay procedure. The specimens were added directly to the assay tubes without extraction steps. The reaction between antibody and ligands was optimal at 1 h. Albumin-coated charcoal was used to separate bound from free radioactivity. Quenching, which occurred with hemolyzed specimens, was corrected by a wet oxidation process with 60% perchloric acid and 30% hydrogen peroxide. The shorter incubation times resulted in an assay that takes less than 6 h to complete. The average affinity constant of the antibody (Km) was 1.75 X 10(10) liters/mol. The sensitivity was 1 ng per assay or 10 ng/ml. Among the other trichothecenes tested, only H-T-2 cross-reacted significantly (10.3%).

Intrinsic factor, free of R proteins, can be prepared from mouse stomach and used in a ligand assay specific for "true" cobalamin.

A ligand assay specific for cobalamin that uses mouse stomach as the source of intrinsic factor has been developed. When mouse stomach extract incubated with radiocobalamin is fractionated by gel chromatography, the radioactive complex elutes as a single peak with apparent molecular weight of 54,900. Formation of the complex is greater than 98% inhibited by human anti-intrinsic factor antibody. When the equivalent of 10,000 pg/ml of cobinamide is added to serum, the apparent cobalamin concentration detected averages 8.5 pg/ml. Correlation with the Lactobacillus leichmannii microbiologic assay results in the regression equation y = 0.97x + 20. In six patients who had megaloblastic anemia the serum cobalamin by the mouse intrinsic factor ligand assay ranged from 0 to 9 pg/ml. Because the primary source of intrinsic factor is free of R proteins, there is no need for extensive purification of the extract. The assay is sensitive, precise, and accurate, and no more difficult to perform than other conventional ligand assay procedures.