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The intrinsic stochasticity of patients' response to treatment is a major consideration for clinical decision‐making in radiation therapy. Markov models are powerful tools to capture this stochasticity and render effective treatment decisions. This paper provides an overview of the Markov models for clinical decision analysis in radiation oncology. A comprehensive literature search was conducted within MEDLINE using PubMed, following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Only studies published from 2000 to 2023 were considered. Selected publications were summarized in two categories: (i) studies that compare two (or more) fixed treatment policies using Monte Carlo simulation and (ii) studies that seek an optimal treatment policy through Markov Decision Processes (MDPs). Relevant to the scope of this study, 61 publications were selected for detailed review. The majority of these publications (n = 56) focused on comparative analysis of two or more fixed treatment policies using Monte Carlo simulation. Classifications based on cancer site, utility measures and the type of sensitivity analysis are presented. Five publications considered MDPs with the aim of computing an optimal treatment policy; a detailed statement of the analysis and results is provided for each work. As an extension of Markov model‐based simulation analysis, MDP offers a flexible framework to identify an optimal treatment policy among a possibly large set of treatment policies. However, the applications of MDPs to oncological decision‐making have been understudied, and the full capacity of this framework to render complex optimal treatment decisions warrants further consideration. [ABSTRACT FROM AUTHOR]

Background A neonatal mortality prediction score can assist clinicians in making timely clinical decisions to save neonates’ lives by facilitating earlier admissions where needed. It can also help reduce unnecessary admissions. Objective The study aimed to develop and validate a prognosis risk score for neonatal mortality within 28 days in public hospitals in the Amhara region, Ethiopia. Methods The model was developed using a validated neonatal near miss assessment scale and a prospective cohort of 365 near-miss neonates in six hospitals between July 2021 and January 2022. The model’s accuracy was assessed using the area under the receiver operating characteristics curve, calibration belt, and the optimism statistic. Internal validation was performed using a 500-repeat bootstrapping technique. Decision curve analysis was used to evaluate the model’s clinical utility. Results In total, 63 of the 365 neonates died, giving a neonatal mortality rate of 17.3% (95% CI: 13.7–21.5). Six potential predictors were identified and included in the model: anemia during pregnancy, pregnancy-induced hypertension, gestational age less than 37 weeks, birth asphyxia, 5 min Apgar score less than 7, and birth weight less than 2500 g. The model’s AUC was 84.5% (95% CI: 78.8–90.2). The model’s predictive ability while accounting for overfitting via internal validity was 82%. The decision curve analysis showed higher clinical utility performance. Conclusion The neonatal mortality predictive score could aid in early detection, clinical decision-making, and, most importantly, timely interventions for high-risk neonates, ultimately saving lives in Ethiopia.

ObjectivesTo develop and validate a values clarification tool, the Short Graphic Values History Tool (GVHT), designed to support person-centred decision making during serious illness.MethodsThe development phase included input from experts and laypersons and assessed acceptability with patients/family members. In the validation phase, we recruited additional participants into a before-after study. Our primary validation hypothesis was that the tool would reduce scores on the Decisional Conflict Scale (DCS) at 1-2 weeks of follow-up. Our secondary validation hypotheses were that the tool would improve values clarity (reduce scores) more than other DCS subscales and increase engagement in advance care planning (ACP) processes related to identification and discussion of one's values.ResultsIn the development phase, the tool received positive overall ratings from 22 patients/family members in hospital (mean score 4.3; 1=very poor; 5=very good) and family practice (mean score 4.5) settings. In the validation phase, we enrolled 157 patients (mean age 71.8 years) from family practice, cancer clinic and hospital settings. After tool completion, decisional conflict decreased (-6.7 points, 95% CI -11.1 to -2.3, p=0.003; 0-100 scale; N=100), with the most improvement seen in the values clarity subscale (-10.0 points, 95% CI -17.3 to -2.7, p=0.008; N=100), and the ACP-Values process score increased (+0.4 points, 95% CI 0.2 to 0.6, p=0.001; 1-5 scale; N=61).ConclusionsThe Short GVHT is acceptable to end users and has some measure of validity. Further study to evaluate its impact on decision making during serious illness is warranted.

This essay argues for two conclusions. First, clinical decision-making is not best thought of as analogous to the purchase of other services, such as car repair. Health-care decision-making is far more difficult, collaborative, emotionally fraught, and subject to cognitive distortions. Second, the provision of health care should not be delegated to unregulated markets. Unlike other markets, there is no reason to expect health-care market outcomes to be efficient or fair or to promote individual freedom, properly conceived. Markets may play an important role in implementing an allocation of healthcare, but they are not an ethically acceptable alternative to determining what that allocation should be. [ABSTRACT FROM AUTHOR]

Decision-making in healthcare is a multifaceted process that involves multiple actors and factors. It is a crucial process that directly influences the quality of care provided to patients. To make appropriate clinical decisions, it is essential to have accurate clinical information, including medical histories and test results, in addition to considering ethical principles. Interdisciplinary consultation, proper documentation, and institutional policies play a vital role in ethical and clinical decision-making, especially in complex situations. Research utilizes methods such as COPRAS and neutrosophic correlation coefficients to guide decision-making in complex situations, but it is emphasized that results may vary depending on the method used and the subjectivity of experts. The results highlight the importance of ethical principles in clinical decision-making, including doing good, avoiding harm, treating all patients fairly, and respecting patient autonomy. The combination of clinical information, ethical principles, and active participation of patients and their families is essential for making informed and ethical decisions that promote the health and well-being of patients.

Simple Summary: A substantial number of patients with cancer receive inappropriate end-of-life care. Improving the quality of end-of-life care is a priority for both patients and their families. Palliative care has been demonstrated to improve the quality of life of patients with a life-threatening illness or frailty. The aim of our retrospective study was to assess whether cancer patients who were provided with specialist palliative care more than a month before their death were less likely to receive inappropriate end-of-life care than patients who were not. We analysed the hospital administrative data of 2603 deceased patients with cancer and found that 690 patients (27%) received potentially inappropriate care in their last month of life. Specialist palliative care was provided to 359 patients (14%). The likelihood for them to receive inappropriate end-of-life care was 45% lower than for patients who were not provided with specialist palliative care. A substantial number of patients with life-threatening illnesses like cancer receive inappropriate end-of-life care. Improving their quality of end-of-life care is a priority for patients and their families and for public health. To investigate the association between provision, timing, and initial setting of hospital-based specialist palliative care and potentially inappropriate end-of-life care for patients with cancer in two acute care hospitals in the Netherlands, we conducted a retrospective observational study using hospital administrative databases. All adults diagnosed with or treated for cancer in the year preceding their death in 2018 or 2019 were included. The main exposure was hospital-based specialist palliative care initiated >30 days before death. The outcome measures in the last 30 days of life were six quality indicators for inappropriate end-of-life care (≥2 ED-visits, ≥2 hospital admissions, >14 days hospitalization, ICU-admission, chemotherapy, hospital death). We identified 2603 deceased patients, of whom 14% (n = 359) received specialist palliative care >30 days before death (exposure group). Overall, 27% (n = 690) received potentially inappropriate end-of-life care: 19% in the exposure group, versus 28% in the non-exposure group (p < 0.001). The exposure group was 45% less likely to receive potentially inappropriate end-of-life care (AOR 0.55; 95% CI 0.41 to 0.73). Early (>90 days) and late (≤90 and >30 days) initiation of specialist palliative care, as well as outpatient and inpatient initiation, were all associated with less potentially inappropriate end-of-life care (AOR 0.49; 0.62; 0.32; 0.64, respectively). Thus, timely access to hospital-based specialist palliative care is associated with less potentially inappropriate end-of-life care for patients with cancer. The outpatient initiation of specialist palliative care seems to enhance this result. [ABSTRACT FROM AUTHOR]

Background: Medication reconciliation is the process of examining the patient's entire medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care. This helps to prevent unintentional inconsistencies across transitions in medical care. Medication reconciliation protects patients from medication side effects while ensuring that they receive standard care. It serves as the baseline from which therapeutic interventions are developed, drug treatment is continued upon admission, and self-care is continued upon release. Objectives: Determining the frequency and kinds of discrepancies discovered during medication reconciliation was the main goal of this study. Determining the effect of medication reconciliation to assess the possible seriousness of medication inconsistencies and ascertain the drug's role in medication errors was the secondary goal. Methodology: In the inpatient units of a tertiary care hospital in the West Godavari District, a prospective, observational study on medication reconciliation was conducted for six months. Results: Of the 385 patients that made up this study, 224 (58.18%) were males and 161 (41.8%) were females. In 169 (43.89%) of the patients, medication discrepancies were detected. There were inconsistencies discovered at several transition points: 50 disparities were detected at admission, 50 during the transfer phase, and 17 on the discharge. Conclusion: A multi-centric assessment including parameters like the percentage of inpatients encountering at least one major medication error would be intriguing. This may support the idea that drug reconciliation is crucial for patient safety. [ABSTRACT FROM AUTHOR]

Decision-making in healthcare is a multifaceted process that involves multiple actors and factors. It is a crucial process that directly influences the quality of care provided to patients. To make appropriate clinical decisions, it is essential to have accurate clinical information, including medical histories and test results, in addition to considering ethical principles. Interdisciplinary consultation, proper documentation, and institutional policies play a vital role in ethical and clinical decisionmaking, especially in complex situations. Research utilizes methods such as COPRAS and neutrosophic correlation coefficients to guide decision-making in complex situations, but it is emphasized that results may vary depending on the method used and the subjectivity of experts. The results highlight the importance of ethical principles in clinical decision-making, including doing good, avoiding harm, treating all patients fairly, and respecting patient autonomy. The combination of clinical information, ethical principles, and active participation of patients and their families is essential for making informed and ethical decisions that promote the health and well-being of patients. [ABSTRACT FROM AUTHOR]

The increasing access to health data worldwide is driving a resurgence in machine learning research, including data-hungry deep learning algorithms. More computationally efficient algorithms now offer unique opportunities to enhance diagnosis, risk stratification, and individualised approaches to patient management. Such opportunities are particularly relevant for the management of older patients, a group that is characterised by complex multimorbidity patterns and significant interindividual variability in homeostatic capacity, organ function, and response to treatment. Clinical tools that utilise machine learning algorithms to determine the optimal choice of treatment are slowly gaining the necessary approval from governing bodies and being implemented into healthcare, with significant implications for virtually all medical disciplines during the next phase of digital medicine. Beyond obtaining regulatory approval, a crucial element in implementing these tools is the trust and support of the people that use them. In this context, an increased understanding by clinicians of artificial intelligence and machine learning algorithms provides an appreciation of the possible benefits, risks, and uncertainties, and improves the chances for successful adoption. This review provides a broad taxonomy of machine learning algorithms, followed by a more detailed description of each algorithm class, their purpose and capabilities, and examples of their applications, particularly in geriatric medicine. Additional focus is given on the clinical implications and challenges involved in relying on devices with reduced interpretability and the progress made in counteracting the latter via the development of explainable machine learning. [ABSTRACT FROM AUTHOR]

Objective: To determine normative values for the Inner Effectiveness of Auditory Rehabilitation (Inner EAR) scale, a validated instrument utilized to study the impact of hearing loss and potential treatments. Study Design: Observational outcomes study. Setting: Academic medical center and community care sites. Methods: We included patients who were at least 18 years of age and completed the Inner EAR scale, pure‐tone audiometry, and word recognition score assessment. Based on audiometry results, patients were categorized as having: (1) normal bilateral hearing, (2) unilateral hearing loss, and (3) bilateral hearing loss. The distributions of Inner EAR scale scores were assessed within each category. Fisher's exact test was utilized to determine whether data‐driven threshold values could discriminate among the 3 clinical groups. Results: Two hundred and twenty‐two consecutive patients with hearing‐related complaints met inclusion criteria. Mean Inner EAR scores for patients with bilateral hearing loss (29.2, interquartile range [IQR] 10‐41.5), unilateral hearing loss (38.9, IQR 23‐49), and normal hearing (46.6, IQR 31‐62) were significantly different (analysis of variance F < 0.0001). An Inner EAR score threshold of 50 supported the ability to statistically significantly discriminate between bilateral hearing loss and normal hearing (p =.003), as well as between unilateral hearing loss and normal hearing (p =.015). Conclusion: An Inner EAR score normative threshold value of 50 provides significant discriminatory ability between normal hearing and unilateral or bilateral hearing loss on audiometry. Normative values provide useful, frequently referenced data when assessing responses to treatment. Based on these data, this threshold may help distinguish patients with and without perceived functional impact from hearing loss. [ABSTRACT FROM AUTHOR]

Abstract Background Resources for healthcare professionals, patients and those important to them relating to planning and coordinating treatment and care at the end of life are abundant, and can be difficult to navigate. However, they have not been systematically collated or catalogued in terms of their purpose, scope or intended audience. Aim To collate, categorise and characterise advance care planning and end-of-life treatment and care (EoLT + C) resources directed towards healthcare professionals, patients and their families. Methods Rapid review and thematic synthesis of resources available in the United Kingdom. Google searches and reviews of websites belonging to selected organisations that develop and publish materials relating to EoLT + C, and advance care planning were used. Materials were included if they were intended for those over 18 living in the UK and pertained to five domains of EoLT + C: identifying those approaching end of life; accessing EoLT + C services; conducting important conversations about EoLT + C and preferences; advance care planning, including recording of preferences and plans; and ensuring that plans and preferences are accessed and used by health and social care services. Results 246 resources directed at healthcare professionals, patients and their families were identified, collated, catalogued and made internationally available for clinicians, researchers, patients and the public. 61 were classified as interactive, providing decision support in EoLT + C that went beyond simply providing information. Of these, there was notable content overlap among tools for identifying patients in their last year of life. There was variation in the development of tools across all domains of end-of-life care by geography and patient group. Few interactive resources integrated seamlessly with a digital interface or healthcare provider workflows. Incentives for the adoption of best-practice appeared rare. Conclusions We present a repeatable and scalable approach to the cataloguing and characterisation of palliative care resources. The identified resources will be of benefit not only to those in the UK but to those in other countries, developing or evaluating their own resources for aiding professionals and patients to plan and deliver excellent treatment and care at the end of life.

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. [ABSTRACT FROM AUTHOR]

The strength of Predictive analytics lies in the ability to reveal interesting patterns obscured within the data and aid the decision-making process. Predictive analytics when deployed using high-end techniques, tools, and methods plays a significant life savior role in the early detection and diagnosis of several human diseases. This research work proposes the implementation of predictive analytics using a multi-stratified algorithm named the “Local Weight Global Mean K-Nearest Neighbor (LWGMK-NN)” under the supervised classification category built over the foundation of analytical techniques without any preset assumptions to discover insights and make predictions. Ten standard clinical datasets are considered to demonstrate the performance of the proposed work against nine state-of-the-art classification algorithms: Logistic Regression, Decision trees, Gaussian Naive Bayes, Random Forest, Linear Support Vector Machine, Stochastic Gradient Descent, Artificial Neural Networks, and XGBoost used as benchmark algorithms. Experimental results shown through performance metrics obtained for simple random sampling, 5-fold cross-validation- a statistical re-sampling method, and 5 times iterated 5-fold cross-validation techniques justify the efficiency of the LWGMK-NN algorithm, and its implementation as a predictive model.

Background: Resources for healthcare professionals, patients and those important to them relating to planning and coordinating treatment and care at the end of life are abundant, and can be difficult to navigate. However, they have not been systematically collated or catalogued in terms of their purpose, scope or intended audience. Aim: To collate, categorise and characterise advance care planning and end-of-life treatment and care (EoLT + C) resources directed towards healthcare professionals, patients and their families. Methods: Rapid review and thematic synthesis of resources available in the United Kingdom. Google searches and reviews of websites belonging to selected organisations that develop and publish materials relating to EoLT + C, and advance care planning were used. Materials were included if they were intended for those over 18 living in the UK and pertained to five domains of EoLT + C: identifying those approaching end of life; accessing EoLT + C services; conducting important conversations about EoLT + C and preferences; advance care planning, including recording of preferences and plans; and ensuring that plans and preferences are accessed and used by health and social care services. Results: 246 resources directed at healthcare professionals, patients and their families were identified, collated, catalogued and made internationally available for clinicians, researchers, patients and the public. 61 were classified as interactive, providing decision support in EoLT + C that went beyond simply providing information. Of these, there was notable content overlap among tools for identifying patients in their last year of life. There was variation in the development of tools across all domains of end-of-life care by geography and patient group. Few interactive resources integrated seamlessly with a digital interface or healthcare provider workflows. Incentives for the adoption of best-practice appeared rare. Conclusions: We present a repeatable and scalable approach to the cataloguing and characterisation of palliative care resources. The identified resources will be of benefit not only to those in the UK but to those in other countries, developing or evaluating their own resources for aiding professionals and patients to plan and deliver excellent treatment and care at the end of life. [ABSTRACT FROM AUTHOR]

Background: Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions. Objective: To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high‐value interventions on the management of non‐specific low back pain. Design: Scoping review. Methods: We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non‐specific low back pain. Results: Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high‐income countries including, the United States, Canada and UK. Twenty‐six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors. Conclusion: Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed. [ABSTRACT FROM AUTHOR]

Background: End-of-life care among surgical patients is largely understudied and far fewer studies examine such care from the family perspective. To identify potential opportunities for improvement, we explored responses of family members of veterans who died following surgery using the Veterans Affairs (VAs) Bereaved Family Survey (BFS)., Methods: We examined data from the BFS open-text responses to explore insights into surgical patient's end-of-life care. Data were analysed iteratively using qualitative content analysis and clustered into domains based on content., Results: We evaluated 936 open-text responses to the BFS for all decedents who underwent any high-risk surgical procedure across 124 VA medical centres from 2010 to 2019. This report focused on the following domains: patient needs, family/caregiver needs, clinical teams/personnel characteristics and facility/organisational characteristics. Key themes within patient needs included concerns about pain management, preservation of patient dignity and spiritual support. Within the family/caregiver domain, key themes included enhanced communication needs, assistance with logistics and displays of gratitude for the patient's military service. The clinical team's domain included the key themes of professionalism concerns and understaffing. Finally, key themes identified within the facility/organisation domain were the need for more robust support services and discomfort with the physical space., Conclusions: Narratives from the family perspective provide valuable insight into end-of-life care among surgical patients. Our data demonstrate the critical need for preserving patient dignity and improved communication, which emphasises family involvement and shared decision-making. In addition, hospital systems can optimise nurse-to-patient ratios and intentionally design physical spaces to help improve end-of-life care for surgical patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Assisted dying has been legally available in Oregon in the USA for 25 years, since when official reports have been published each year detailing the number of people who have used this option as well as sociodemographic and information about the process. The aim of this study was to examine changes over time in these data., Methods: We collated and reviewed data on 2454 assisted deaths included in annual reports on assisted deaths published by the Oregon Health Authority from 1998 to 2022. Descriptive statistics were used to describe time trends., Results: The number of assisted deaths in Oregon increased from 16 in 1998 to 278 in 2022. Over this time, patients' health funding status changed from predominantly private (65%) to predominantly government support (79.5%), and there was an increase in patients feeling a burden and describing financial concerns as reasons for choosing an assisted death. There has been a reduction in the length of the physician-patient relationship from 18 weeks in 2010 to 5 weeks in 2022, and the proportion referred for psychiatric assessment remains low (1%). Data are frequently missing, particularly around complications., Conclusions: The number and characteristics of people accessing assisted deaths, and the process, have changed since data collection started in 1998. Prospective studies are needed to examine the relationship between socioeconomic factors and the desire for an assisted death in Oregon., Competing Interests: Competing interests: CR provides content for the website ‘Keep Assisted Dying Out of Healthcare’. IF is a board member of Living & Dying Well and is co-chair of the All Party Parliamentary Group for Dying Well. AW was a part-time paid researcher for Living and Dying Well from June 2021 to June 2022., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Point-of-Care-Testing (PoCT) has emerged as an essential component of modern healthcare, providing rapid, low-cost, and simple diagnostic options. The integration of Machine Learning (ML) into biosensors has ushered in a new era of innovation in the field of PoCT. This article investigates the numerous uses and transformational possibilities of ML in improving biosensors for PoCT. ML algorithms, which are capable of processing and interpreting complicated biological data, have transformed the accuracy, sensitivity, and speed of diagnostic procedures in a variety of healthcare contexts. This review explores the multifaceted applications of ML models, including classification and regression, displaying how they contribute to improving the diagnostic capabilities of biosensors. The roles of ML-assisted electrochemical sensors, lab-on-a-chip sensors, electrochemiluminescence/chemiluminescence sensors, colorimetric sensors, and wearable sensors in diagnosis are explained in detail. Given the increasingly important role of ML in biosensors for PoCT, this study serves as a valuable reference for researchers, clinicians, and policymakers interested in understanding the emerging landscape of ML in point-of-care diagnostics.

Hepatocellular carcinoma (HCC) is a common liver malignancy and represents a serious cause of cancer-related mortality and morbidity. One of the favourable curative surgical therapeutic options for HCC is liver transplantation (LT) in selected patients fulfilling the known standard Milan/University of California San Francisco criteria which have shown better outcomes and longer-term survival. Despite careful adherence to the strict HCC selection criteria for LT in different transplant centres, the recurrence rate still occurs which could negatively affect HCC patients' survival. Hence HCC recurrence post-LT could predict patients' survival and prognosis, depending on the exact timing of recurrence after LT (early or late), and whether intra/extrahepatic HCC recurrence. Several factors may aid in such a complication, particularly tumour-related criteria including larger sizes, higher grades or poor tumour differentiation, microvascular invasion, and elevated serum alpha-fetoprotein. Therefore, managing such cases is challenging, different therapeutic options have been proposed, including curative surgical and ablative treatments that have shown better outcomes, compared to the palliative locoregional and systemic therapies, which may be helpful in those with unresectable tumour burden. To handle all these issues in our review., Competing Interests: Conflict-of-interest statement: The author declares no conflict of interests for this article., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objectives: To conduct a scoping review to explore the evidence of the process of do not attempt cardiopulmonary resuscitation (DNACPR) decision-making., Methods: We conducted a systematic search and review of articles from 1 January 2013 to 6 April 2023 within eight databases. Through multi-disciplinary discussions and content analytical techniques, data were mapped onto a conceptual framework to report the data., Results: Search results (n=66 207) were screened by paired reviewers and 58 papers were included in the review. Data were mapped onto concepts/conceptual framework to identify timing of decision-making, evidence of involvement, evidence of discussion, evidence of decision documented, communication and adherence to decision and recommendations from the literature., Conclusion: The findings provide insights into the barriers and facilitators to DNACPR decision-making, processes and implementation. Barriers arising in DNACPR decision-making related to timing, patient/family input, poor communication, conflicts and ethical uncertainty. Facilitators included ongoing conversation, time to discuss, documentation, flexibility in recording, good communication and a DNACPR policy. Challenges will persist unless substantial changes are made to support and promote examples of good practice. Overall, the review underlined the complexity of DNACPR decision-making and how it is a process shaped by multiple factors including law and policy, resource investment, healthcare professionals, those close to the patient and of central importance, the patient., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Decision-making processes (DMPs) can be altered by several factors that might impact patient outcomes. However, nurses’ views and experiences regarding the multitude of personal and organizational factors that may facilitate or inhibit their decision-making abilities have rarely been studied. Purpose: To explore the personal and organizational factors that influence nurse DMPs in clinical settings at Ministry of Health hospitals (MOH). Method: A qualitative research design was conducted. A purposive sample of 52 nurses was recruited from general and critical wards in two major Ministry of Health hospitals in Hail, Saudi Arabia. A total of eight focus groups (semi-structured interviews) were conducted to elicit participant responses. Results: In this study, the personal differences covered nurses’ experience, physical and psychological status, autonomy, communication skills, values, and cultural awareness. Organizational factors included the availability of resources, organizational support, workload, the availability of educational programs, the availability of monitoring programs, and the consistency and unity of policies, rules, and regulation applications. Conclusions: The major contribution of this study is the comprehensive illustration of influential factors at both the personal level and the organizational level that impact DMPs to achieve desired outcomes for patients and health organizations. This study utilizes a framework that could explain the nature of nurse DMPs.

Atrial fibrillation-no primary care physician can escape it! Atrial fibrillation is the most common tachyarrhythmia encountered in clinical practice-whether family practice, internal medicine, cardiology, pulmonology medicine, etc. Moreover, with growth of the older segment of our population and better survival of patients with cardiovascular disorders, the incidence and prevalence of atrial fibrillation are both increasing progressively. Currently, a review of major guidelines shows that the treatment approach to atrial fibrillation involves 4 "pillars"-treatment of contributory comorbidities ("upstream therapy"), control of the ventricular response to the rapid atrial rates during atrial fibrillation, prevention of thromboembolism with oral anticoagulation or left atrial appendage occlusion (except in the minority of patients at too low a thromboembolic risk), and rhythm control in those patients who require it. The latter is the most complex of the 4, and many, if not most, primary care physicians currently prefer to leave this "pillar" to the care of a cardiologist or electrophysiologist. Nonetheless, it is important for the primary care physician to be familiar with the rhythm treatment components and choices (both overall and, specifically, the ones in which they must participate) as they will impact many interactions with their patients in multiple ways. This review details for the primary care physician the components of care regarding rhythm control of atrial fibrillation and the areas in which the primary care physician/internist must be knowledgeable and proactively involved. [ABSTRACT FROM AUTHOR]

Abstract In order to improve the diagnosis and treatment of senile thyroid diseases in China and to promote healthy aging, the Endocrine Metabolic Diseases Group of the Chinese Geriatrics Society, and the Thyroid Group of the Chinese Society of Endocrinology jointly drafted the “Expert consensus on diagnosis and treatment for Chinese elderly with thyroid diseases” (referred to as consensus). The Consensus consists of five parts that set 40 recommendations on main clinical issues. The consensus emphasizes clinical focus on the age‐related changes of the hypothalamus‐pituitary‐thyroid axis in the elderly, and it recommends application of comprehensive geriatric assessment to thoroughly evaluate the impact of thyroid diseases and relevant intervention on overall health condition. Meanwhile, it recommends generalization of screening for hypothyroidism during admission to nursing institution or hospital, and routine health check‐ups. Furthermore, it develops individualized stratified management on hyperthyroidism, hypothyroidism, thyroid nodules, and differentiated thyroid carcinoma in the elderly distinguished from the youngers, including treatment regimen, control ranges, and flowcharts for diagnosis and treatment. The Consensus will provide the basis for clinical decisions and health management of thyroid diseases in the elderly by geriatrician, endocrinologist, and general practitioners.

Objective: The aim of this research is to study the impact of first continuous electroencephalographic (cEEG) monitoring on clinical decisions and outcomes of pediatric patients in a Thai Tertiary Center. Methods: Pediatric patients less than 15 years old underwent cEEG. Enrollment and data collection were part of a prospective analytical descriptive study. Results: Forty-four cEEG monitorings were included. Every patient chosen for cEEG monitoring had alteration of consciousness. Some of these patients also had paroxysmal events, and some were treated with a hypothermia process. Non-convulsive status epilepticus (NCSE) was detected in 27.3% of the monitorings. NCSE was found in patients diagnosed with febrile infection related epilepsy syndrome (FIRES), epilepsy, urea cycle defect with severe diffuse encephalopathy, lead encephalopathy, hydrocephalus, subdural hemorrhage, myocarditis with cardiac arrest and GM1 gangliosidosis. CEEG led to specific clinical decisions 45.5% of the time. Clinical decisions included changes in antiepileptic drug usage and urgent neuroimaging. The short term outcome for NCSE patients was poor but not statistically significantly different from that of non-NCSE patients. Conclusions: This study confirms the findings of prior publications by establishing the benefit of cEEG monitoring. The first cEEG monitoring of children in a Thai Tertiary Center impacted clinical decisions and patient outcomes in the majority of patients by providing an opportunity to detect NCSE or problems leading to appropriate clinical management.

Abstract Background Cost control and usage regulation of medical materials (MMs) are the practical issues that the government pays close attention to. Although it is well established that there is great potential to mobilize doctors and patients in participating MMs-related clinical decisions, few interventions adopt effective measures against specific behavioral deficiencies. This study aims at developing and validating an independent consultation and feedback system (ICFS) for optimizing clinical decisions on the use of MMs for inpatients needing joint replacement surgeries. Methods Development of the research protocol is based on a problem or deficiency list derived on a trans-theoretical framework which incorporates including mainly soft systems-thinking, information asymmetry, crisis-coping, dual delegation and planned behavior. The intervention consists of two main components targeting at patients and doctors respectively. Each of the intervention ingredients is designed to tackle the doctor and patient-side problems with MMs using in joint replacement surgeries. The intervention arm receives 18 months' ICFS intervention program on the basis of the routine medical services; while the control arm, only the routine medical services. Implementation of the intervention is supported by an online platform established and maintained by the Quality Assurance Center for Medical Care in Anhui Province, a smartphone-based application program (APP) and a web-based clinical support system. Discussion The implementation of this study is expected to significantly reduce the deficiencies and moral hazards in decision-making of MMs using through the output of economic, efficient, sustainable and easy-to-promote cooperative intervention programs, thus greatly reducing medical costs and standardizing medical behaviors. Trial registration number ISRCTN10152297.

Introduction: Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high‐value interventions in the management of non‐specific LBP. Methods: This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand‐searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim. Ethics and dissemination: This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non‐specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics. [ABSTRACT FROM AUTHOR]

Background: A neonatal mortality prediction score can assist clinicians in making timely clinical decisions to save neonates' lives by facilitating earlier admissions where needed. It can also help reduce unnecessary admissions., Objective: The study aimed to develop and validate a prognosis risk score for neonatal mortality within 28 days in public hospitals in the Amhara region, Ethiopia., Methods: The model was developed using a validated neonatal near miss assessment scale and a prospective cohort of 365 near-miss neonates in six hospitals between July 2021 and January 2022. The model's accuracy was assessed using the area under the receiver operating characteristics curve, calibration belt, and the optimism statistic. Internal validation was performed using a 500-repeat bootstrapping technique. Decision curve analysis was used to evaluate the model's clinical utility., Results: In total, 63 of the 365 neonates died, giving a neonatal mortality rate of 17.3% (95% CI: 13.7-21.5). Six potential predictors were identified and included in the model: anemia during pregnancy, pregnancy-induced hypertension, gestational age less than 37 weeks, birth asphyxia, 5 min Apgar score less than 7, and birth weight less than 2500 g. The model's AUC was 84.5% (95% CI: 78.8-90.2). The model's predictive ability while accounting for overfitting via internal validity was 82%. The decision curve analysis showed higher clinical utility performance., Conclusion: The neonatal mortality predictive score could aid in early detection, clinical decision-making, and, most importantly, timely interventions for high-risk neonates, ultimately saving lives in Ethiopia.

Objective: While the professional version of the Mobile App Rating Scale (MARS) has already been translated, and validated into the Spanish language, its user-centered counterpart has not yet been adapted. Furthermore, no other similar tools exist in the Spanish language. The aim of this paper is to adapt and validate User Version of the MARS (uMARS) into the Spanish language.Materials and Methods: Cross-cultural adaptation, translation, and metric evaluation. The internal consistency and test-retest reliability of the Spanish version of the uMARS were evaluated using the RadarCovid app. Two hundred and sixteen participants rated the app using the translated scale. The app was then rated again 2 weeks later by 21 of these participants to measure test-retest reliability.Results: No major differences were observed between the uMARS original and the Spanish version. Discrimination indices (item-scale correlation) obtained appropriate results for both raters. The Spanish uMARS presented with excellent internal consistency, α = .89 and .67 for objective and subjective quality, respectively, and temporal stability (r > 0.82 for all items and subscales).Discussion: The Spanish uMARS is a useful tool for health professionals to recommend high-quality mobile apps to their patients based on the user's perspective and for researchers and app developers to use end-user feedback and evaluation, to help them identify highly appraised and valued components, as well as areas for further development, to continue ensuring the increasing quality and prominence of the area of mHealth.Conclusion: uMARS Spanish version is an instrument with adequate metric properties to assess the quality of health apps from the user perspective. [ABSTRACT FROM AUTHOR]

This article focuses on the main results of a quantitative empirical study of clinical decisions made by doctors in medical institutions of various profiles in a large Russian city. The study was conducted in 2019 and is based on the results of the previous qualitative analysis stage — within the research “mix-strategy”. The main point of analytical interest is the factors which influence the doctors’ clinical decisions in two basic clinical situations — in the situation of disease diagnosis and in the situation of treatment prescription. The object of the research was doctors from Samara medical clinics. Factors and decisions made by doctors were studied from the point of view of doctors themselves. The degree of influence of each factor on the decisions made by doctors was assessed with the help of the Influence Index, an integral index on a fully ordered scale. The article presents a hierarchy of factors influencing medical decision-making in diagnosis and treatment situations; the top group of factors in both situations is identified and interpreted. At the same time, additional problematic situations were studied in the research. In particular, the range of clinical decisions and factors determining them, in case of it being necessary to conduct an examination not provided by standard state medical care, in a situation when this examination is provided, but the limit of prescriptions is exhausted, in a situation when the medical institution (hospital) does not have the best quality medication for the patient in the quantities needed, in a situation when the state standard on a specific nosology is ineffective for a specific patient, as well as other problematic situations.

Objectives: Shape of training has recognised that 'Managing End-of-Life and Applying Palliative Care Skills' is a key competency for internal medicine trainees. It provides the opportunity and challenge to improve palliative care training for generalist physicians. Simulation has been recognised internationally as a holistic teaching and assessment method. This study aimed to produce a palliative medicine simulation training package for internal medicine trainees for delivery by palliative medicine trainees providing the former opportunity to practice assessment and management of patients with life-limiting illness and the latter teaching and management opportunities., Methods: A regional group of palliative medicine trainees were trained in simulation and debrief. Nominal and focus group techniques designed a simulation training package. Learning outcomes were mapped to the internal medicine curriculum descriptors., Results: Palliative simulation for internal medicine trainees (PALL-SIM-IMT) is a training package meeting internal medicine trainees' curriculum requirements. Regional pilots have demonstrated feasibility for delivery by palliative medicine trainees and improvement in recipients' confidence in all curriculum descriptors., Conclusions: PALL-SIM-IMT can aid competency achievement for the provision of generalist palliative care by internal medicine trainees. It allows reciprocal development of palliative medicine trainees' leadership and teaching skills. National adoption and evaluation is ongoing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The study aimed to assess outcomes in patients undergoing liver biopsy for metastatic cancer, focusing on mortality rates and chemotherapy following their biopsy., Methods: Hospital Episode Statistics data from 2010 to 2019 identified 30 992 patients with metastatic cancer who underwent percutaneous liver biopsy. Primary outcomes included 14-day and 30-day mortality rates, as well as the proportion receiving chemotherapy within 6 months., Results: 30 992 patients were studied (median age of 69 (IQR 59-74) years, 52% female). 28% underwent inpatient biopsy with 8% dying within 14 days and 26% within 30 days. Outpatient biopsies had lower mortality rates: 2.2% at 14 days and 8.6% at 30 days.30-day mortality was associated with: inpatient biopsy (OR 3.5 (95% CI 3.26 to 3.76)) and increasing comorbidity (Charlson score 1-4: 1.21 (95% CI 1.11 to 1.32)); but negatively with all ages under 70 (eg, for 18-29 years 0.35 (95% CI 0.20 to 0.63)) and biopsy at a radiotherapy centre (0.88 (95% CI 0.82 to 0.95)).46% of patients received chemotherapy within 6 months of biopsy (53% with outpatient biopsies but only 33% with inpatient biopsies). Receiving chemotherapy was associated with: all ages under 70 (eg, 18-29 years 3.3 (95% CI 2.62 to 5.30)), female sex (1.06 (95% CI 1.01 to 1.11)) and medium (1.13 (95% CI 1.04 to 1.22) and high (1.49 (95% CI 1.38 to 1.62)) volume liver biopsy providers; but negatively with inpatient biopsy (0.45 (95% CI 0.43 to 0.48)) and increasing comorbidity (Charlson score 1-4: 0.85 (95% CI 0.79 to 0.91))., Conclusions: Mortality rates following liver biopsy for metastatic cancer are notably higher among patients undergoing emergency inpatient procedures. Clinicians should carefully weigh the risks and benefits of biopsy in elderly, comorbid or poor performance status patients. Multidisciplinary approaches involving palliative care may aid in decision-making for these patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To assess the outcomes of percutaneous nephrostomy in England for renal decompression, in the context of metastatic cancer., Methods: Retrospective observational study of all patients undergoing nephrostomy with a diagnosis of metastatic cancer from 2010 to 2019 in England, identified and followed up within Hospital Episode Statistics.The primary outcome measure was mortality (14-day and 30-day postprocedure). Secondary outcomes included subsequent chemotherapy or surgery and direct complications of nephrostomy., Results: 10 932 patients were identified: 58.0% were male, 51.0% were >70 years old and 57.7% had no relevant comorbidities (according to Charlson's criteria, other than cancer).1 in 15 patients died within 14 days of nephrostomy and 1 in 6 died within 30 days. Factors associated with higher 30-day mortality were the presence of comorbidities (Charlson score 1-4 (OR 1.27, 95% CI 1.08 to 1.50, p=0.003), score 5+ (OR 1.29, 95% CI 1.14 to 1.45), p<0.001)); inpatient nephrostomy (OR 3.76, 95% CI 2.75 to 5.14, p<0.001) and admitted under the care of specialities of internal medicine (OR 2.10, 95% CI 1.84 to 2.40, p<0.001), oncology (OR 1.80, 95% CI 1.51 to 2.15, p<0.001), gynaecology/gynaeoncology (OR 1.66, 95% CI 1.21 to 2.28, p=0.002) or general surgery (OR 1.62, 95% CI 1.32 to 1.98, p<0.001)), compared with urology.25.4% received subsequent chemotherapy. Receiving chemotherapy was associated with younger patients (eg, age 18-29 (OR 4.04, 95% CI 2.66 to 6.12, p<0.001) and age 30-39 (OR 3.07, 95% CI 2.37 to 3.97, p<0.001)) and under the care of oncology (OR 1.60, 95% CI 1.40 to 1.83, p<0.001) or gynaecology/gynaeoncology (OR 1.64, 95%CI 1.28 to 2.10, p<0.001) compared with urology.43.8% had subsequent abdominopelvic surgery. Not receiving surgery was associated with inpatient nephrostomy (OR 0.82, 95%CI 0.72 to 0.95,p=0.007): non-genitourinary cancers (eg, gynaecology/gynaeoncology cancer (OR 0.86, 95% CI 0.74 to 0.99, p=0.037)); and under the care of a non-surgical specialty (medicine (OR 0.69, 95% CI 0.63 to 0.77, p<0.001), oncology (OR 0.58, 95% CI 0.51 to 0.66, p<0.001)).24.5% of patients had at least one direct complication of nephrostomy: 12.5% required early exchange of nephrostomy, 8.1% had bleeding and 6.7% had pyelonephritis., Conclusions: The decision to undertake nephrostomy in patients with poor prognosis cancer is complex and should be undertaken in a multidisciplinary team setting. Complication rates are high and minimal survival benefit is derived in many patients, especially in the context of emergency inpatient care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Time is crucial for patients with metastatic breast cancer (MBC), and clinicians are expected to determine the optimal timing for best supportive care (BSC) transition but no evident marker has been established. We recently revealed that absolute lymphocyte count (ALC) was a prognostic marker for patients with MBC. Thus, we investigated whether ALC could be an indicator of the best timing for the BSC transition., Methods: 101 patients with MBC were retrospectively investigated, and the relationship between clinicopathological factors, including ALC, and the duration of the last treatment was analysed., Results: Mean ALC significantly gradually decreased during the last three systemic treatments towards BSC transition. Patients of younger age, with special histology type, hormone receptor-positive tumours and low ALC at the start of the last treatment had significantly shorter time-to-treatment-termination (TTT) for the last treatment. When ALC was classified into low and high, the mean TTT of the last treatment in the ALC-low group was significantly shorter (16.4 weeks) compared with that in the ALC-high group (30.2 weeks; p=0.004)., Conclusions: Our data suggest that ALC values, which decrease as MBC progresses, could serve as a potential indicator for determining the optimal timing of BSC transition., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Although randomised controlled trials are considered the gold standard in clinical research, they are not always feasible due to limitations in the study population, challenges in obtaining evidence, high costs and ethical considerations. As a result, single-arm trial designs have emerged as one of the methods to address these issues. Single-arm trials are commonly applied to study advanced-stage cancer, rare diseases, emerging infectious diseases, new treatment methods and medical devices. Single-arm trials have certain ethical advantages over randomised controlled trials, such as providing equitable treatment, respecting patient preferences, addressing rare diseases and timely management of adverse events. While single-arm trials do not adhere to the principles of randomisation and blinding in terms of scientific rigour, they still incorporate principles of control, balance and replication, making the design scientifically reasonable. Compared with randomised controlled trials, single-arm trials require fewer sample sizes and have shorter trial durations, which can help save costs. Compared with cohort studies, single-arm trials involve intervention measures and reduce external interference, resulting in higher levels of evidence. However, single-arm trials also have limitations. Without a parallel control group, there may be biases in interpreting the results. In addition, single-arm trials cannot meet the requirements of randomisation and blinding, thereby limiting their evidence capacity compared with randomised controlled trials. Therefore, researchers consider using single-arm trials as a trial design method only when randomised controlled trials are not feasible., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The aim of this study is to evaluate the effectiveness of web-based decision aids (WDAs) on cancer-related clinical care in terms of different decision categories and by different cancer types. Methods: Literature retrieval utilized highly inclusive algorithms searching randomized controlled trials (RCTs) in MEDLINE, EMBASE, and Cochrane Library and manual searching of eligible studies from reference lists of relevant articles. Two researchers examined the articles selected separately and extracted the information about the studies (e.g., decision category, sample sizes, and outcome indicators) using a data-extracting form and performed risk of bias assessment of the included studies with Begg's test, Egger's test, and Cochrane Collaboration's tool. Meta-analysis of the pooled effects of WDAs on outcome indicators was performed via Review Manager 5.2. Results: A total of 24 RCTs met the inclusion criteria, involving 9846 participants. Overall meta-analysis revealed statistically significant effects on cancer decisional conflict, knowledge, and making informed choice with the overall effect sizes being –0.29 (standardized mean difference, SMD), 0.47 (SMD), and 1.92 (risk ratio, RR) respectively. Subgroup analysis revealed significant effects in indicators including decisional conflict, knowledge, satisfaction, participation in decision-making, and screening behavior, though some extent of heterogeneity and quality flaws existed among the included studies. Conclusions: Although our research results showed evidence of WDA effects on certain outcome indicators of cancer decisions, these results should be interpreted with caution given the heterogeneity and quality flaws. It is still premature to conclude whether WDA was effective in optimizing cancer clinical decision-making, and more efforts are needed in this area. PROSPERO registration number: CRD42020218991 [ABSTRACT FROM AUTHOR]

Decision-making processes (DMPs) can be altered by several factors that might impact patient outcomes. However, nurses' views and experiences regarding the multitude of personal and organizational factors that may facilitate or inhibit their decision-making abilities have rarely been studied. Purpose: To explore the personal and organizational factors that influence nurse DMPs in clinical settings at Ministry of Health hospitals (MOH). Method: A qualitative research design was conducted. A purposive sample of 52 nurses was recruited from general and critical wards in two major Ministry of Health hospitals in Hail, Saudi Arabia. A total of eight focus groups (semi-structured interviews) were conducted to elicit participant responses. Results: In this study, the personal differences covered nurses' experience, physical and psychological status, autonomy, communication skills, values, and cultural awareness. Organizational factors included the availability of resources, organizational support, workload, the availability of educational programs, the availability of monitoring programs, and the consistency and unity of policies, rules, and regulation applications. Conclusions: The major contribution of this study is the comprehensive illustration of influential factors at both the personal level and the organizational level that impact DMPs to achieve desired outcomes for patients and health organizations. This study utilizes a framework that could explain the nature of nurse DMPs. [ABSTRACT FROM AUTHOR]

Objectives: To explore factors contributing to decisions to transfuse platelets in cancer care outside guidelines using case study methods. Methods: Two case studies were examined, using instrumental case study methodology, to qualitatively explore factors that influence the decision to transfuse platelets. Interviews (n=10) were conducted around cases in haematology and critical care. In‐depth review of documentary evidence was undertaken and propositions were developed to provide rigour during the investigation. Thematic analysis and triangulation of documents was undertaken to find specific factors, and propositions analysed, as per instrumental case study methods. Results: Both cases emphasised how patient complexity, and individual response to platelet administration, was an influencing factor. Other themes included uncertainty of clinical situations coupled with uncertainty about platelet availability. Other factors worthy of further investigation include the concept of professional safety and the trustworthiness of platelet thresholds against platelet monitoring for bleeding episodes. Conclusion: The findings indicated several factors influence decisions to transfuse, including clinical context, and individual ability to trust guidelines and assume any perceived risks. [ABSTRACT FROM AUTHOR]

Prevalence of discrepancies between antemortem clinical diagnoses and postmortem autopsy findings is uncertain in pediatric oncology given improving diagnostic capabilities over time. Primary objective was to describe discrepancies between antemortem and postmortem diagnosis of pediatric cancer deaths. Secondary objective was to compare clinical characteristics of deaths with and without major diagnostic discrepancies. This was a retrospective study that included pediatric cancer patients diagnosed and treated in Ontario and who died from 2003 to 2012. Antemortem clinical diagnoses associated with mortality were determined by reviewing the patient's health records 2 weeks prior to death while the postmortem diagnoses were determined by the autopsy report. Discrepancies among these diagnoses were classified using the Goldman criteria where major discrepancies were directly related to the cause of death in contrast to minor discrepancies. Among the 821 patients who died, 118 (14%) had an autopsy and were included. Of these autopsies, 12 (10%) had a major diagnostic discrepancy between antemortem and postmortem diagnoses. Major discrepancies consisted of opportunistic infections (n = 5), missed cancer diagnosis (n = 3), and organ complications (n = 4). Death in a high acuity setting (12/12, 100% vs. 60/106, 57%; P = 0.003) and treatment-related mortality (12/12, 100% vs. 60/106, 57%; P = 0.003) were significantly associated with major discrepancy. Major diagnostic discrepancy was found in 10% of pediatric oncology autopsies. Missed infections and organ complications were predominant etiologies. Death in a high acuity setting and treatment-related mortality were associated with major diagnostic discrepancies. Autopsies continue to be important for improving diagnostic insight and may improve future clinical care. [ABSTRACT FROM AUTHOR]

Background: There is growing attention to evidence-based practice in Australian clinical contexts and nursing literature. Recent research explores the dimensions of evidence-based practice; however, the implementation of evidence-based clinical decision making has been identified as a cumbersome process. Aim: This study aimed to review the literature systematically regarding the system factors and their possible impacts on the process of evidence-based practice implementation. Method: Anelectronic search on major databases, including MEDLINE, PsycINFO, PubMed, ProQuest, Google Scholar, and CINAHL was conducted from January 2018 to March 2018. A rigorous selection process focusing on the inclusion of nurses in the study population and the system factors related to their practices resulted in the selection of 18 articles. Data were extracted from the studies and grouped into categories using a thematic analysis. Results: The factors affecting the nurses' evidence-based practice were identified at the individual, team, and organizational culture levels. The individual domain included a lack of education and clinical expertise, inadequate research skills, time constraint, and low levels of confidence and autonomy in changing practices. The factors identified at the team level associated with a lack of research orientation and peer support. At the organizational culture level, poor research culture and infrastructure were identified as important factors. Implications for Practice: The findings of the system factors would help policymakers to redefine the nursing practice. Moreover, the results raise the nurse's awareness about the importance of using evidence-based practice in decision making.

Abstract Background To analyze data in terms of the glycaemic control and therapeutic regimens used for Type-2 Diabetes Mellitus (T2DM) management in Greece, identify factors that influence clinical decisions and determine the level of compliance of T2DM management with the latest international and local guidelines. Methods ‘AGREEMENT’ was a national-multicenter, non-interventional, cross-sectional disease registry. A total of 1191 adult T2DM patients were enrolled consecutively from 59 sites of the National Health System (NHS) or University Hospitals, representing the majority of Diabetes centers or Diabetes outpatient clinics in Greece with a broad geographic distribution. Patients were stratified by gender and analysis was done according to 3 treatment strategies: A (lifestyle changes or use of one oral antidiabetic agent), B (up to 3 antidiabetic agents including injectables but not insulin) and C (any regimens with insulin). Results Mean (±SD) HbA1c % of the total population was 7.1 (±1.2) while mean (±SD) FPG (mg/dl) was measured at 136 (±42). The proportion of patients who achieved HbA1c

Abstract Background Recent studies have shown that psychological factors, attitudes and beliefs impact on the quality of chiropractic student clinical decisions. This association has not been studied among qualified chiropractors. Our objective was to investigate if personality, psychological factors and/or unorthodox beliefs among chiropractors are related to choices of management in specific clinical scenarios. Method In February 2018, a subsample of chiropractors (N = 700) from a practitioner-based research network in Australia known as ACORN (N = 1680), were invited to respond to an on-line anonymous questionnaire. Questions included items relating to management of specific clinical scenarios, intolerance of uncertainty (IU) and the ‘Big-5’ personality score, adoption of a prescriptive technique system, self-rating of chiropractic abilities, and the level of importance of subluxation and chiropractic philosophy in the delivery of care. Descriptive analysis was to be reported and associations examined between i) personality and psychology factors, unorthodox beliefs and ii) scores obtained for management of specific clinical scenarios, numbers of interdisciplinary referrals, and guideline-based X-ray use. Results The number of respondents was 141 (20%) and 33 of their responses were largely incomplete resulting in a final response rate of 108 (15.4%). In addition, some questions were left unanswered. These related mainly to IU and Big-5 personality measurements. Some sample characteristics (age, number of patients per week, hours worked per week) were similar to the larger ACORN project sample. However, the low response rate indicated that the final study sample was unlikely to be truly representative of the study population and the low number of participants made association testing unsuitable. Conclusion and recommendations The low response rate and small study sample in this study made any substantive analysis inappropriate. For these reasons, the study was not concluded. However, the potential reasons for the low response from this large database of volunteer research participants are of interest and need to be investigated. Clearly, it is necessary to engage this population better to explore sensitive issues such as personality inventories and different practice profiles in the interest of effective health care delivery and patient safety.

Background: Children's healthcare needs are complex and diverse. Paramedics are expected to respond to a range of emergency calls across the patient demographic spectrum and to make complex clinical decisions, whilst facing growing pressures to seek provisions of care for their patients within the community. Aim: This study looked to understand the lived experiences of paramedics when attending to paediatric patients, and what factors influenced decision making. Methods: A qualitative study employing semi-structured interviews, to collect and describe the lived experiences of participants. Participants were paramedics working for an ambulance service responding to calls in the community. Participants varied in experience and registrant level of education. Interview data were transcribed verbatim and analysed utilising inductive thematic analysis. Results: Education provoked the most discussion, with a desire for more knowledge and training to improve confidence when attending to patients with low acuity complaints. Confidence was found to be intrinsically linked to experience, with clinicians who were more exposed to paediatrics in their professional or personal life displaying more confidence when attending to this patient group. Emotion of clinicians and/or families contributes to the clinical decision-making process; coupled with a reliance on clinical guidelines, there is a high probability of a paediatric consultation resulting in conveyance to an emergency department. Provision of care was variable geographically, with largely negative experiences observed with attempts for community referrals. Conclusions: Providing a focus of education more reflective of paramedics' experiences will address some of the factors discussed by participants. Introducing innovative solutions such as developing guidelines for lower acuity conditions and the introduction of specialist roles could contribute to mitigating the barriers paramedics faced while improving the quality of care provided to paediatric patients. Barriers to confidence existing due to lack of exposure may well still exist, as would options to refer to community services. [ABSTRACT FROM AUTHOR]