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Piech P, Haratym M, Borowski B, Węgłowski R, Staśkiewicz G. Beyond the fractures: A comprehensive Comparative analysis of Affordable and Accessible laboratory parameters and their coefficients for prediction and Swift confirmation of pulmonary embolism in high-risk orthopedic patients. Pract Lab Med 2024; 40:e00397. [PMID: 38737854 PMCID: PMC11088337 DOI: 10.1016/j.plabm.2024.e00397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024] Open
Abstract
Background Pulmonary embolism (PE) poses a significant challenge in diagnosis and treatment, particularly in high-risk patient populations such as those hospitalized for orthopedic reasons. This study explores the predictive and diagnostic potential of laboratory parameters in identifying PE among orthopedic patients. Objectives The purpose of this study was to determine whether selected (inexpensive and readily available) laboratory parameters and their coefficients can be used to diagnose pulmonary embolism and whether they are applicable in predicting its occurrence. Material and methods Selected laboratory parameters were determined twice in 276 hospitalized orthopedic patients with suspected PE: PLT, MPV, NEU, LYM, D-dimer, troponin I, age-adjusted D-dimer and their coefficients. Depending on the angio-CT results, patients were divided into groups. Selected popular laboratory coefficients were calculated and statistically analyzed. Optimal cutoff points were determined for the above laboratory tests and ROC curves were plotted. Results D-dimer/troponin I [p = 0.008], D-dimer [p = 0.001], age-adjusted D-dimer [p = 0.007], NLR/D-dimer [p = 0.005] and PLR [p = 0.021] are statistically significant predictors of PE. D-dimer/troponin I [p < 0.001], troponin I [p = 0.005] and age-adjusted D-dimer [p = 0.001] correlated with the diagnosis of PE after the onset of clinical symptoms. Conclusions In the context of orthopedic patients, cost-effective laboratory parameters, particularly the D-dimer/troponin I ratio and age-adjusted D-dimer, exhibit considerable potential in predicting and diagnosing PE. These findings suggest that combining readily available laboratory tests with clinical observation can offer a viable and cost-effective diagnostic alternative, especially in resource-constrained settings. Further studies with larger and diverse patient populations are recommended to validate these results.
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Affiliation(s)
- Piotr Piech
- Department of Normal, Clinical and Imaging Anatomy, Medical University of Lublin, Poland
- Department of Orthopedics and Traumatology, Medical University of Lublin, Poland
| | - Mateusz Haratym
- Research Group of Normal, Clinical and Imaging Anatomy, Medical University of Lublin, Poland
| | - Bartosz Borowski
- Research Group of Normal, Clinical and Imaging Anatomy, Medical University of Lublin, Poland
| | - Robert Węgłowski
- Department of Normal, Clinical and Imaging Anatomy, Medical University of Lublin, Poland
| | - Grzegorz Staśkiewicz
- Department of Normal, Clinical and Imaging Anatomy, Medical University of Lublin, Poland
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Rahimi F, Rabiei R, Seddighi AS, Roshanpoor A, Seddighi A, Moghaddasi H. Features and functions of decision support systems for appropriate diagnostic imaging: a scoping review. Diagnosis (Berl) 2024; 11:4-16. [PMID: 37795534 DOI: 10.1515/dx-2023-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/10/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND Diagnostic imaging decision support (DI-DS) systems could be effective tools for reducing inappropriate diagnostic imaging examinations. Since effective design and evaluation of these systems requires in-depth understanding of their features and functions, the present study aims to map the existing literature on DI-DS systems to identify features and functions of these systems. METHODS The search was performed using Scopus, Embase, PubMed, Web of Science, and Cochrane Central Registry of Controlled Trials (CENTRAL) and was limited to 2000 to 2021. Analytical studies, descriptive studies, reviews and book chapters that explicitly addressed the functions or features of DI-DS systems were included. RESULTS A total of 6,046 studies were identified. Out of these, 55 studies met the inclusion criteria. From these, 22 functions and 22 features were identified. Some of the identified features were: visibility, content chunking/grouping, deployed as a multidisciplinary program, clinically valid and relevant feedback, embedding current evidence, and targeted recommendations. And, some of the identified functions were: displaying an appropriateness score, recommending alternative or more appropriate imaging examination(s), providing recommendations for next diagnostic steps, and providing safety alerts. CONCLUSIONS The set of features and functions obtained in the present study can provide a basis for developing well-designed DI-DS systems, which could help to improve adherence to diagnostic imaging guidelines, minimize unnecessary costs, and improve the outcome of care through appropriate diagnosis and on-time care delivery.
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Affiliation(s)
- Fatemeh Rahimi
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Rabiei
- Department of Health Information Technology and Management, Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saied Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Roshanpoor
- Department of computer, Yadegar-e-Imam Khomeini (RAH), Janat-abad Branch, Islamic Azad University, Tehran, Iran
| | - Afsoun Seddighi
- Functional Neurosurgery Research Center, Shohada Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Moghaddasi
- Department of Health Information Technology and Management, Health Information Management & Medical Informatics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Darband St., Tehran, Iran
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Ban JW, Perera R, Williams V. Influence of research evidence on the use of cardiovascular clinical prediction rules in primary care: an exploratory qualitative interview study. BMC PRIMARY CARE 2023; 24:194. [PMID: 37730553 PMCID: PMC10512575 DOI: 10.1186/s12875-023-02155-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians' perceptions of and experiences with research influence their use of cardiovascular CPRs. METHODS We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes. RESULTS Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians' perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: "Seek and judge" and "be acquainted and assume." When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs. CONCLUSIONS Clinicians' perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians' unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.
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Affiliation(s)
- Jong- Wook Ban
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK.
- Department for Continuing Education, University of Oxford, Oxford, UK.
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Mercurio L, Corwin D, Kaplan R, Ellison AM, Casper TC, Kuppermann N, Kline JA. Bedside exclusion of pulmonary embolism in children without radiation (BEEPER): a national study of the Pediatric Emergency Care Applied Research Network-Study protocol. Res Pract Thromb Haemost 2023; 7:100046. [PMID: 36865906 PMCID: PMC9971278 DOI: 10.1016/j.rpth.2023.100046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 10/18/2022] [Accepted: 10/23/2022] [Indexed: 01/15/2023] Open
Abstract
Background The Pulmonary Embolism Rule Out Criteria (PERC) Peds rule, derived from the PERC rule, was derived to estimate a low pretest probability for pulmonary embolism (PE) in children but has not been prospectively validated. Objective The objective of this study was to present a protocol for an ongoing multicenter prospective observational study that evaluates the diagnostic accuracy of the PERC-Peds rule. Methods This protocol is identified by the acronym, BEdside Exclusion of Pulmonary Embolism without Radiation in children. The study aims were designed to prospectively validate, or if necessary, refine, the accuracy of PERC-Peds and D-dimer in excluding PE among children with clinical suspicion or testing for PE. Multiple ancillary studies will examine clinical characteristics and epidemiology of the participants. Children aged 4 through 17 years were being enrolled at 21 sites through the Pediatric Emergency Care Applied Research Network (PECARN). Patients taking anticoagulant therapy are excluded. PERC-Peds criteria data, clinical gestalt, and demographic information are collected in real time. The criterion standard outcome is image-confirmed venous thromboembolism within 45 days, determined from independent expert adjudication. We assessed interrater reliability of the PERC-Peds, frequency of PERC-Peds use in routine clinical care, and descriptive characteristics of missed eligible and missed patients with PE. Results Enrollment is currently 60% complete with an anticipated data lock in 2025. Conclusions This prospective multicenter observational study will not only test whether a set of simple criteria can safely exclude PE without need for imaging but also provide a resource to fill a critical knowledge gap about clinical characteristics of children with suspected and diagnosed PE.
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Affiliation(s)
- Laura Mercurio
- Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daniel Corwin
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ron Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Angela M. Ellison
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theron Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine and UC Davis Health, Sacramento, California
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan
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Ehrman RR, Malik AN, Smith RK, Kalarikkal Z, Huang A, King RM, Green RD, O'Neil BJ, Sherwin RL. Serial use of existing clinical decisions aids can reduce computed tomography pulmonary angiography for pulmonary embolism. Intern Emerg Med 2021; 16:2251-2259. [PMID: 33742340 DOI: 10.1007/s11739-021-02703-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) remains a diagnostic challenge in emergency medicine. Clinical decision aids (CDAs) like the Pulmonary Embolism Rule-Out Criteria (PERC) are sensitive but poorly specific; serial CDA use may improve specificity. The goal of this before-and-after study was to determine if serial use of existing CDAs in a novel diagnostic algorithm safely decreases the use of CT pulmonary angiograms (CTPA). This was a retrospective before-and-after study conducted at an urban ED with 105,000 annual visits. Our algorithm uses PERC, Wells' score, and D-dimer in series, before moving to CTPA. The algorithm was introduced in January, 2017. Use of CDAs and D-dimer in the 24 months pre- and 12 months post-intervention were obtained by chart review. The algorithm's effect on CTPA ordering was assessed by comparing volume 5 years pre- and 3 years post-intervention, adjusted for ED volume. Mean CTPAs per 1000 adult ED visits was 11.1 in the 5 pre-intervention years and 9.9 in the 3 post-intervention years (p < 0.0001). Use of PERC, Wells' score and D-dimer increased from 1.1%, 1.1%, and 28% to 8.8% (p = 0.0002) 8.1% (p = 0.0005), and 35% (p = 0.0066), respectively. Pre-intervention, there were six potentially missed PEs compared to three in the post-intervention period. Introduction of our serial CDA diagnostic algorithm was associated with increased use of CDAs and D-dimer and reduced CTPA rate without an apparent increase in the number of missed PEs. Prospective validation is needed to confirm these results.
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Affiliation(s)
- Robert Russell Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA.
| | - Adrienne Nicole Malik
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Reid Kenneth Smith
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Zeid Kalarikkal
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Andrew Huang
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Ryan Michael King
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Rubin David Green
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
| | - Brian James O'Neil
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Detroit Receiving Hospital, Detroit, USA
| | - Robert Leigh Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI, 48201, USA
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Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med 2019; 74:285-296. [PMID: 30611639 DOI: 10.1016/j.annemergmed.2018.10.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 10/08/2018] [Accepted: 10/29/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE As electronic health records evolve, integration of computerized clinical decision support offers the promise of sorting, collecting, and presenting this information to improve patient care. We conducted a systematic review to examine the scope and influence of electronic health record-integrated clinical decision support technologies implemented in the emergency department (ED). METHODS A literature search was conducted in 4 databases from their inception through January 18, 2018: PubMed, Scopus, the Cumulative Index of Nursing and Allied Health, and Cochrane Central. Studies were included if they examined the effect of a decision support intervention that was implemented in a comprehensive electronic health record in the ED setting. Standardized data collection forms were developed and used to abstract study information and assess risk of bias. RESULTS A total of 2,558 potential studies were identified after removal of duplicates. Of these, 42 met inclusion criteria. Common targets for clinical decision support intervention included medication and radiology ordering practices, as well as more comprehensive systems supporting diagnosis and treatment for specific disease entities. The majority of studies (83%) reported positive effects on outcomes studied. Most studies (76%) used a pre-post experimental design, with only 3 (7%) randomized controlled trials. CONCLUSION Numerous studies suggest that clinical decision support interventions are effective in changing physician practice with respect to process outcomes such as guideline adherence; however, many studies are small and poorly controlled. Future studies should consider the inclusion of more specific information in regard to design choices, attempt to improve on uncontrolled before-after designs, and focus on clinically relevant outcomes wherever possible.
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Dubin J, Wilson M, Frohna W. Comments on "Knowledge Translation of the PERC Rule for Suspected Pulmonary Embolism: A Blueprint for Reducing the Number of CT Pulmonary Angiograms". West J Emerg Med 2018; 19:474. [PMID: 29762610 PMCID: PMC5942011 DOI: 10.5811/westjem.2018.2.36889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/21/2018] [Accepted: 02/20/2018] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jeffrey Dubin
- MedStar Emergency Physicians, MedStar Washington Hospital Center/Georgetown Department of Emergency Medicine, Washington, District of Columbia
| | - Matthew Wilson
- MedStar Emergency Physicians, MedStar Washington Hospital Center/Georgetown Department of Emergency Medicine, Washington, District of Columbia
| | - William Frohna
- MedStar Emergency Physicians, MedStar Washington Hospital Center/Georgetown Department of Emergency Medicine, Washington, District of Columbia
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