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The rational use of water while considering the increases in food production is a great challenge for agriculture currently. The aim of the present study was to evaluate the soil properties of rice paddy areas under different water management systems. For this, the rice cultivars BRS Tropical and IRGA 424 were grown under the following treatments: M1: Intermittent flooding; M2: Intermittent flooding, followed by continuous flooding; M3: Continuous flooding, followed by intermittent flooding; and M4: Continuous flooding for the entire plant cycle. As a control, a non-cultivated area, adjacent to the experimental plots was also evaluated. The variables analyzed were P, K+, Ca2+, Mg2+ and Al3+ contents, pH, soil organic carbon (SOC), total nitrogen (TN) Carbon Stock (C-Stock), nitrogen stock (N-Stock), Cation-exchange capacity (CEC), C/N ratio; CO2 emission, soil microbial biomass carbon (SMB), metabolic coefficient (qMic) and acid phosphatase and urease activities. There was not difference among the different water management systems for P, K+, Mg2+, CEC and C/N ratio. The SMB and the acid phosphatase and urease activities were lower under the different treatments when compared to the control. The CO2 emission under rice paddy system was influenced by the phenological phase of the crop. The variables SOC, C-Stock, SMB, C/N ratio, K+, acid phosphatase and usease activities are those most sensitive attributes observed in the soil under different water management systems during rice cultivation. Water management in the rice paddy system influenced soil by changing its quality. RESUMO O uso racional da água na produção de alimentos é um desafio no cenário atual. Objetivou-se no presente estudo avaliar as características do solo em área de arroz irrigado sob diferentes sistemas de manejo da água. Para isso, avaliou-se os sistemas de manejos de irrigação do arroz: M1- Inundação intermitente; M2- Inundação intermitente na fase vegetativa até 50% de floração média, seguida de inundação contínua até a maturação; M3- Inundação contínua na fase vegetativa até 50% de floração, seguida de inundação intermitente até a maturação e M4- Inundação contínua durante todo o ciclo e duas cultivares BRS Tropical e IRGA 424. Como controle, uma área não cultivada, também foi avaliada. Avaliou-se os teores de P, K+, Ca2+, Mg2+, Al3+ e H + Al, pH, carbono orgânico do solo (COS), nitrogênio total, estoque de carbono, estoque de nitrogênio, capacidade de troca catiônica, relação C/N; Emissão de CO2, carbono da biomassa microbiana do solo (CBMS), coeficiente metabólico (qMic) e atividades da fosfatase e da urease. Não houve diferença entre os sistemas de manejo de água quanto aos atributos P, K+ e Mg2+, CTC e relação C/N. O CBMS, as atividades da fosfatase e urease foram mais baixas em todos tratamentos quando comparados ao controle. A emissão de CO2 foi influenciada pela fase fenológica da cultura. O COS, estoque de carbono, CBMS, relação C/N, K+ e atividades da fosfatase foram os atributos mais sensíveis nos diferentes sistemas O manejo da água influencia as propriedades do solo, alterando sua qualidade.

Background: The most active agents for the treatment of breast cancer are the anthracyclines whose clinical usefulness is limited by cumulative dose-dependent cardiotoxicity, which results in congestive heart failure among other limiting factors. With all the attempts to minimize chemotherapeutic cardiotoxicity, remote ischemic preconditioning (RIPC) has been considered as a potent endogenous mechanism capable of inhibiting inflammatory responses. Objective: This study aimed to verify if RIPC may be effective as prophylaxis to prevent anthracycline- induced cardiotoxicity in oncological patients. Methods: The preconditioning method was based on four to five-minute cycles of a blood pressure cuff insufflation around the upper arm (either left or right) from 200 mmHg to 250 mmHg, inducing ischemic intervals interspersed with 5 minutes of reperfusion. Results: In this work, echocardiogram results showed a ventricular mass variation that can get worse during chemotherapeutic treatment; however, in patients who had been undergoing RIPC sessions over a period of 6 months, it was observed that this change did not occur. The parameters for troponin T levels were considered; they were higher in patients who were not undergoing RIPC in relation to those who were. When both cases were compared, it was possible to infer that there was a clinically significant improvement for those who went through the procedure. Conclusion: Thus, through the analysis of this study, it is possible to conclude that RIPC is a lowcost, non-invasive procedure which brings cardiac protection for patients undergoing chemotherapy with anthracyclines, providing support in the treatment of cancer.

Background Capturing accurate clinical data in real time is a challenge during public health emergencies. The United States Critical Illness and Injury Trials Group-Program for Emergency Preparedness is committed to improving these preparedness efforts. Objectives We aimed to create an electronic Acute Physiology and Chronic Health Evaluation (APACHE) II data collection instrument that (1) leverages Research Electronic Data Capture (REDCap) automated calculations and logic, (2) may be shared across sites, (3) overcomes limitations in existing APACHE II instruments in the REDCap library, and (4) suggests changes to be made to data collection instruments during emergencies. Methods The APACHE II instrument was implemented using REDCap. Data fields were divided into four sections: age, Acute Physiology, Glasgow Coma Scale, and chronic health status. Usability testing was followed by two preliminary evaluations: a comparison to existing APACHE II instruments and a simulated emergency exercise. Results The final instrument consisted of 34 data fields. It produced an accurate APACHE II score and was faster to complete than two previous implementations (average of 97.5 seconds vs. 323.5 and 183.5 seconds). During the simulated emergency exercise, the instrument was used at 10 sites to create 34 patient records; median time to complete the instrument was 150.5 seconds. Conclusion This project demonstrated feasibility of improving the accuracy and efficiency of a data collection instrument. Future efforts should focus on expanding these methods to develop other scoring tools for use during emergencies and additional testing to ensure it is ready for use during a real emergency.

The Sao Paulo Microtron 10 − 100 keV electron beam-line described here was designed to allow precise measurements of the electron-atom interaction cross-sections using reproducible arrangements. The irradiation chamber has thirteen spectroscopy windows for x-ray detectors and a multi-target ladder. The photon background on the target was reduced by using a large and deep Faraday cup, lining the chamber's interior with plastic, and mounting the targets in carbon fiber frames. The current research plan includes measurements of: electron doubly differential bremsstrahlung cross sections; inner shell ionization cross sections; angular distributions of L X-rays, and the angular distribution of scattered electrons.

Gastric emptying (GE) and food tolerance (FT) can be altered after Roux-en-Y gastric bypass (RYGB) has been performed, especially when it involved the use of a restrictive mechanism (such as a silastic ring). To assess GE and FT in patients who underwent banded (BRYGB) or non-banded Roux-en-Y gastric bypass (RYGB). Forty-seven BRYGB patients and 47 RYGB patients underwent gastric emptying scintigraphy (GES) and FT assessment (by means of a questionnaire) between 6 months and 2 years postoperatively. GES was performed on average 11.7 ± 5.0 months (6 to 24) postoperatively. T½ medians (time taken for the gastric radioactivity to decrease to half of the original value in the gastric pouch) in the RYGB and BRYGB groups were 48.7 min (40.6–183.0 min) and 56.3 min (41.1–390.9 min), respectively (p = 0.031). The median of total questionnaire scores was 24 points (18–27) in the RYGB group and 20 points (13–27) in the BRYBG group (p

We investigate how the racial composition of entrepreneurs affects racial differences in labor market outcomes of workers. We create a novel data set that identifies the race of firm owners in Brazil and link it with matched employer-employee data that contains information on the universe of formal employment contracts. We first present evidence of assortative matching between nonwhite workers and nonwhite entrepreneurs. Controlling for a wide set of covariates, we find that the share of nonwhite workers is 18.7% higher in firms with at least one nonwhite owner. We then show that the adjusted racial wage gap is 28% smaller in firms with nonwhite entrepreneurs than in white-owned firms. This is partially explained by nonwhite workers accessing better occupations in firms with nonwhite entrepreneurs. Lastly, we show that nonwhite workers are 15% more likely to become entrepreneurs if they were previously employed by nonwhite entrepreneurs than if they were employed by white entrepreneurs.

Background : The II Brazilian Consensus on Gastric Cancer of the Brazilian Gastric Cancer Association BGCA (Part 1) was recently published. On this occasion, countless specialists working in the treatment of this disease expressed their opinion in the face of the statements presented. Aim : To present the BGCA Guidelines (Part 2) regarding indications for surgical treatment, operative techniques, extension of resection and multimodal treatment. Methods: To formulate these guidelines, the authors carried out an extensive and current review regarding each declaration present in the II Consensus, using the Medline/PubMed, Cochrane Library and SciELO databases initially with the following descriptors: gastric cancer, gastrectomy, lymphadenectomy, multimodal treatment. In addition, each statement was classified according to the level of evidence and degree of recommendation. Results : Of the 43 statements present in this study, 11 (25,6%) were classified with level of evidence A, 20 (46,5%) B and 12 (27,9%) C. Regarding the degree of recommendation, 18 (41,9%) statements obtained grade of recommendation 1, 14 (32,6%) 2a, 10 (23,3%) 2b e one (2,3%) 3. Conclusion : The guidelines complement of the guidelines presented here allows surgeons and oncologists who work to combat gastric cancer to offer the best possible treatment, according to the local conditions available. RESUMO Racional: O II Consenso Brasileiro de Câncer Gástrico da Associação Brasileira de Câncer Gástrico ABCG (Parte 1) foi recentemente publicado. Nesta ocasião inúmeros especialistas que atuam no tratamento desta doença expressaram suas opiniões diante declarações apresentadas. Objetivo: Apresentar as Diretrizes da ABCG (Parte 2) quanto às indicações de tratamento cirúrgico, técnicas operatórias, extensão de ressecção e terapia combinada. Métodos: Para formulação destas diretrizes os autores realizaram extensa e atual revisão referente a cada declaração presente no II Consenso, utilizando as bases Medline/PubMed, Cochrane Library e SciELO, inicialmente com os seguintes descritores: câncer gástrico, gastrectomia, linfadenectomia, terapia combinada. Ainda, cada declaração foi classificada de acordo com o nível de evidência e grau de recomendação. Resultados: Das 43 declarações presentes neste estudo, 11 (25,6%) foram classificadas com nível de evidência A, 20 (46,5%) B e 12 (27,9%) C. Quanto ao grau de recomendação, 18 (41,9%) declarações obtiveram grau de recomendação 1, 14 (32,6%) 2a, 10 (23,3%) 2b e um (2,3%) 3. Conclusão: O complemento das diretrizes aqui presentes possibilita que cirurgiões e oncologistas que atuam no combate ao câncer gástrico possam oferecer o melhor tratamento possível, de acordo com as condições locais disponíveis.

Background: Since the publication of the first Brazilian Consensus on Gastric Cancer (GC) in 2012 carried out by the Brazilian Gastric Cancer Association, new concepts on diagnosis, staging, treatment and follow-up have been incorporated. Aim: This new consensus is to promote an update to professionals working in the fight against GC and to provide guidelines for the management of patients with this condition. Methods: Fifty-nine experts answered 67 statements regarding the diagnosis, staging, treatment and prognosis of GC with five possible alternatives: 1) fully agree; 2) partially agree; 3) undecided; 4) disagree and 5) strongly disagree A consensus was adopted when at least 80% of the sum of the answers “fully agree” and “partially agree” was reached. This article presents only the responses of the participating experts. Comments on each statement, as well as a literature review, will be presented in future publications. Results: Of the 67 statements, there was consensus in 50 (74%). In 10 declarations, there was 100% agreement. Conclusion: The gastric cancer treatment has evolved considerably in recent years. This consensus gathers consolidated principles in the last decades, new knowledge acquired recently, as well as promising perspectives on the management of this disease.

Gastric carcinoma (GC) locoregional recurrence may occur even in cases where the tumor has been completely resected, possibly due to lymph node (LN) micrometastases. It is estimated that in 10% to 30% of cases, LN micrometastases are not detected by a conventional method for histological assessment of LN metastases with hematoxylin-eosin (HE). A cross-sectional study assessed 51 patients with GC by histological evaluation of the LN micrometastases through LN multi sectioning associated with immunohistochemistry analysis with monoclonal antibodies AE1 and AE3. Total gastrectomy was performed in 51% of patients. The total number of resected LN nodes was 1698, with a mean number of resected LN of 33.3 ± 13.2 per surgical specimen, of which 187 had metastasis. After the application of LN multisection and immunohistochemistry, LN micrometastases were found in 45.1% of the cases. LN staging changed in 29.4%, and tumor staging changed in 23.5% of the cases. In patients initially staged as pN0, LN staging and tumor staging changed, both in 19.2% of the cases. In patients initially staged as pN1 or more, LN staging changed in 40.0% of them, and tumor staging changed in 28.0% of the cases. The accuracy of HE for the histological staging of LN tumoral involvement was 76%, which was considered insufficient for CG patients staging. Investigation of LN micrometastasis through LN multisection and immunohistochemistry should be performed, particularly in cases where the presence of blood and lymphatic vessel invasion has been identified after conventional histological analysis, as well as in patients with advanced GC.

Introduction: Breast cancer remains the second most common type of cancer in the world and the first among women, with breast cancer incidence rates doubling in the last thirty years. In 2013, the St Gallen Consensus recommended the use of a study of the multigene profile and phenotyping to indicate adjuvance by use of the MammaPrint and Oncotype4 applications; however, as they are not available in the Unified Health System (Sistema Único de Saúde–SUS), clinical predictive criteria and laboratory tests are used for indication of adjuvant therapy. Objective: Evaluation of clinical and laboratory criteria in the selection of patients with breast cancer after surgery for adjuvant chemotherapy and quantification of the factors used in the selected patients and their results. Method: This is a retrospective, cross-sectional observational study with patients over 18 years of age, without gender and race restriction, diagnosed with breast cancer at a public hospital in São Paulo, from 09/10/18 to 10/12/18, who underwent surgical treatment and discussed adjuvant therapy. Patients with metastatic neoplasia and/or undergoing neoadjuvant treatment were excluded. Data collected were: TNM staging, histological type and hormone receptors, age and comorbidities in all medical records collected. Results: 1,390 consultations were carried out, with 42 patients selected, according to the study criteria. Since 40% of the patients were outside the recommended range for breast cancer screening, regarding TNM, late diagnoses were evidenced, with 69% presenting ≥T2 and 36% with lymph node involvement. Of the 42 patients, 98% received adjuvant therapy. Conclusion: It was evidenced by Paik et al., that 92.1% of the 668 patients enrolled in the NSABP B-14 study were considered of intermediate or high risk according to the NCCN and St. Gallen criteria, and by Oncotype DX, 50.6% of the patients were classified as at low risk of recurrence. However, as these are not available in SUS, the present study shows the need to use clinical and laboratory factors to indicate adjuvant therapy, and with these, of the 42 patients, 98% had indication, showing that they are not such effective means in the use of genetic tests, and patients treated by SUS initiate their treatments late, which impacts disease-free survival, since less than 10% of patients received care with early stage neoplasia.

Sleep disturbances are feasibly linked with poorer outcome in BD. This study aims to cross-sectionally investigate clinical factors associated with sleep disruption in euthymic BD patients. We assessed sleep quality in a sample of 209 euthymic BD patients with the Pittsburgh Sleep Quality Index. After multiple logistic regression analysis controlling for several confounding factors, the variables number of clinical diseases and Hamilton global score remained significant and independently associated with poor sleep quality. Our results suggest that euthymic BD patients presenting poor sleep quality are more likely to have clinical comorbidities and manifest subsyndromal depressive symptomatology.

The aim of this study is to evaluate the interaction between treatment delay and stage on the mortality from non-small cell lung cancer (NSCLC).We performed a survival analysis in a cohort of patients admitted to the reference cancer center. The following data were collected: age, gender, smoking status, tumor staging, type of lung cancer, and time from the date when the patient was diagnosed with cancer to the starting date of effective treatment. Univariable and multivariable Cox proportional hazard models were used to investigate the association between potential confounders identified during the study design. After the final adjusted model was determined, tests for interaction among all predictors were performed.Inclusion criteria were met by 359 patients. In the adjusted analysis, delayed treatment delivery was a protective factor for the risk of death, with a crude hazard ratio (HR) =0.75 (0.59-0.97; P=0.02) and an adjusted HR =0.59 (0.46-0.77; P0.001). However, a statistically significant interaction with mortality was observed between timely treatment and tumor stage. Patients with stage II disease who received delayed treatment had a higher risk of death [HR =3.08 (1.05-9.0; P=0.04)]. On the other hand, stage IV patients who received delayed treatment had a 52% reduction in mortality [HR =0.48 (0.35-0.66; P0.001)].Stage of disease influenced the association between start of the treatment and mortality, and only the subgroup of stage II patients seemed to benefit from early treatment.

Graphical abstract, Background Development and dissemination of public health (PH) guidance to healthcare organizations and the general public (e.g., businesses, schools, individuals) during emergencies like the COVID-19 pandemic is vital for policy, clinical, and public decision-making. Yet, the rapidly evolving nature of these events poses significant challenges for guidance development and dissemination strategies predicated on well-understood concepts and clearly defined access and distribution pathways. Taxonomies are an important but underutilized tool for guidance authoring, dissemination and updating in such dynamic scenarios. Objective To design a rapid, semi-automated method for sampling and developing a PH guidance taxonomy using widely available Web crawling tools and streamlined manual content analysis. Methods Iterative samples of guidance documents were taken from four state PH agency websites, the US Center for Disease Control and Prevention, and the World Health Organization. Documents were used to derive and refine a preliminary taxonomy of COVID-19 PH guidance via content analysis. Results Eight iterations of guidance document sampling and taxonomy revisions were performed, with a final corpus of 226 documents. The preliminary taxonomy contains 110 branches distributed between three major domains: stakeholders (24 branches), settings (25 branches) and topics (61 branches). Thematic saturation measures indicated rapid saturation (≤5% change) for the domains of “stakeholders” and “settings”, and “topic”-related branches for clinical decision-making. Branches related to business reopening and economic consequences remained dynamic throughout sampling iterations. Conclusion The PH guidance taxonomy can support public health agencies by aligning guidance development with curation and indexing strategies; supporting targeted dissemination; increasing the speed of updates; and enhancing public-facing guidance repositories and information retrieval tools. Taxonomies are essential to support knowledge management activities during rapidly evolving scenarios such as disease outbreaks and natural disasters.

Connectors used in electrical power distribution systems should allow the passage of electricity continuously and without interruption. However, this does not always occur due to failure caused by improper assembly and/or corrosion of the materials employed, which reflects the quality of service. Notable among the new detection technologies that have been studied to facilitate the identification of defects is the use of thermochromic materials, which allow the easy identification of "hot spots", without the need for specialized equipment and personnel. In this context, in this study, the performance of a thermochromic liquid crystal was evaluated with the aim of developing a temperature sensor for connectors used in electrical power distribution networks. For the evaluation of the performance, thermal and ultraviolet radiation degradation tests were conducted, as well as analysis using spectroscopic (FTIR, FTIR-HATR, UV-Vis, 1H NMR) and thermal (DSC, PLM) techniques. The results indicated that the liquid crystal and the associated components showed no degradation under the test conditions, as well as a good color stability was observed, verifying the viability of the use of these materials for the construction of a temperature sensor. A field test was performed with the devices and was effective for the suggested application.

Objective To evaluate the prevalence of seven social factors using physician notes as compared to claims and structured electronic health records (EHRs) data and the resulting association with 30-day readmissions. Study Setting A multihospital academic health system in southeastern Massachusetts. Study Design An observational study of 49,319 patients with cardiovascular disease admitted from January 1, 2011, to December 31, 2013, using multivariable logistic regression to adjust for patient characteristics. Data Collection/Extraction Methods All-payer claims, EHR data, and physician notes extracted from a centralized clinical registry. Principal Findings All seven social characteristics were identified at the highest rates in physician notes. For example, we identified 14,872 patient admissions with poor social support in physician notes, increasing the prevalence from 0.4 percent using ICD-9 codes and structured EHR data to 16.0 percent. Compared to an 18.6 percent baseline readmission rate, risk-adjusted analysis showed higher readmission risk for patients with housing instability (readmission rate 24.5 percent; p

Real time data provided by frontline clinicians could be used to direct immediate resources during a public health emergency and inform increased preparedness for future events. The [group name removed for blind review], a group of expert critical care and emergency medicine physicians at various academic medical centers across the US, aims to enhance the national capability of rapid electronic data collection, along with analysis and dissemination of findings. To achieve these aims, [group name removed for blind review] created a process for real-time data capture that relies on a curated and engaged network of clinical providers from various geographical regions to respond to short online “Pulse” queries about healthcare system stress. During a period of three years, five queries were created and distributed. The first two queries were used to develop and validate the data collection infrastructure.Results are reported for the last three queries between June 2015 and March 2016. Response rates consistently ranged from 39% to 42%. Our team demonstrated that our system and processes were ready for creation and rapid dissemination of episodic queries for rapid data collection, transmittal, and analysis through a curated national network of clinician responders during a public health emergency. [group name removed for blind review] aims to further increase the response rate through additional engagement efforts within the network, to continue to grow the clinician responder database, and to optimize additional query content.

The objective of this study was to evaluate the organic carbon (OC) distribution and inorganic phosphorus (P) fractions on different soil aggregates classes under forestry fragment of Atlantic Forest, pasture and agroforestry managed for a long period. Soil samples were collected at depths of 0.00-0.10, 0.10-0.20 and 0.20-0.60 m, and the aggregate stability analysis was performed at each depth. The OC and the inorganic P fractions (Pbic readily available, NaHCO3 0.5 mol L-1; PNa1 moderately available, NaOH 0.1 mol L-1; and PNa2 restricted availability, NaOH 0.5 mol L-1) were determined in the respective classes of soil aggregates 4-2, 2-1, 1-0.5, 0.5-0.25 mm. Soil under forestry fragment showed higher OC contents and regardless the land use, highest values of inorganic P were found in the aggregates > 1 mm. Forestry showed highest levels of Pbic, while agroforestry showed the highest levels of PNa1, and pasture had highest values of PNa2.

Introduction: Gastric gastrointestinal tumors (GIST) are a rare and usually asymptomatic neoplasm that can present as abdominal mass in more advanced scenarios. Since surgical resection is the main aspect of the treatment, locally advanced tumors require multivisceral resection and, therefore, higher postoperative morbidity and mortality. Objective: To perform a review the literature on the topic, with emphasis on the neoadjuvant therapy. Methods: Literature review on the Medline database using the following descriptors: gastrointestinal stromal tumors, neoadjuvant therapy, imatinib mesylate and molecular targeted therapy. Results: Surgical resection remains the cornerstone for the treatment of GISTs; however, tyrosine kinase inhibitors have improved survival as an adjuvant therapy. More recently, neoadjuvant therapy have been described in the treatment of locally advanced tumors in order to avoid multivisceral resection. Conclusion: Despite surgical resection remains as the most important aspect of the treatment of GISTs, adjuvant and neoadjuvant therapy with tyrosine kinase inhibitors have shown to both improve survival and resectability, respectively.

OBJECTIVES: The aim of this study is to evaluate the access of patients with lung cancer in a densely populated area of São Paulo to the Brazilian Public Health System, focusing on the time spent from symptom onset or initial diagnosis until the beginning of treatment. METHODS: We retrospectively reviewed 509 patients with malignant lung neoplasms who were admitted to a single reference oncology center of the public health system between July 2008 and December 2014. Patients were considered eligible for this study if they were older than 18 years and had not undergone any previous oncology treatment when they were admitted to the institution. The following data were collected from all patients: age, gender, smoking status, tumor staging, time from the when the first symptoms were experienced by the patient to when the patient was diagnosed with cancer, time from the first appointment to cancer diagnosis, and time from when the patient was diagnosed with cancer to the initiation of treatment. RESULTS: The median time from symptom onset to diagnosis was three months. From the first appointment to diagnosis, the median time interval was one month; however, 79% of patients were diagnosed in up to two months. The median time from diagnosis to the start of treatment was one month, but most patients (82.5%) started treatment in up to two months. CONCLUSION: In our highly populated region with preferential access to the public health system, patients are required to wait a relatively long time to effectively begin treatment for lung cancer. This type of study is important to alert medical societies and government health agencies.

Background The purpose of this study was to assess the tolerance of early oral feeding after total laryngectomy. Method A randomized multicenter study was conducted that included 89 individuals subjected to total laryngectomy. The participants were allocated to 2 groups: early (n = 44), early oral feeding; and late (n = 45), late oral feeding. The participants in the early group were assessed as to acceptance of oral feeding, and their food intake was quantified. Results In the early group, the total energy expenditure and protein needs were not met through oral feeding alone at any time during the first 7 postoperative days. The times to attain 25% and 50% of the total energy expenditure and protein needs by oral feeding after surgery were 4 and 7 days, respectively. Conclusion The patients subjected to early oral feeding failed to meet their caloric and protein needs through that route alone during the first 4 postoperative days and required complementary nutrition through another route. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Objective Develop a prototype of an interprofessional terminology and information model infrastructure that can enable care planning applications to facilitate patient-centered care, learn care plan linkages and associations, provide decision support, and enable automated, prospective analytics. Design The study steps included a 3 step approach: (1) Process model and clinical scenario development, and (2) Requirements analysis, and (3) Development and validation of information and terminology models. Results Components of the terminology model include: Health Concerns, Goals, Decisions, Interventions, Assessments, and Evaluations. A terminology infrastructure should: (A) Include discrete care plan concepts; (B) Include sets of profession-specific concerns, decisions, and interventions; (C) Communicate rationales, anticipatory guidance, and guidelines that inform decisions among the care team; (D) Define semantic linkages across clinical events and professions; (E) Define sets of shared patient goals and sub-goals, including patient stated goals; (F) Capture evaluation toward achievement of goals. These requirements were mapped to AHRQ Care Coordination Measures Framework. Limitations This study used a constrained set of clinician-validated clinical scenarios. Terminology models for goals and decisions are unavailable in SNOMED CT, limiting the ability to evaluate these aspects of the proposed infrastructure. Conclusions Defining and linking subsets of care planning concepts appears to be feasible, but also essential to model interprofessional care planning for common co-occurring conditions and chronic diseases. We recommend the creation of goal dynamics and decision concepts in SNOMED CT to further enable the necessary models. Systems with flexible terminology management infrastructure may enable intelligent decision support to identify conflicting and aligned concerns, goals, decisions, and interventions in shared care plans, ultimately decreasing documentation effort and cognitive burden for clinicians and patients.

Few studies have shown the importance of different pasture management practices on C storage and the reduction of CO2–C emissions in tropical conditions. The objective of the present study was to determine short-term changes in C pools and C balance from different pasture management practices established in the Atlantic Rainforest. A field study was carried out in Alegre, ES, Brazil from September 2013 to August 2014 to investigate the first-year effect of pasture management practices on a Udult clayey soil. The different pasture management practices studied included the following: control (CON), chiseled (CHI), fertilized (FER), burned (BUR), integrated with crop–livestock (iCL) systems, and plowed and harrowed (PH). Monthly disturbed and undisturbed soil samples were taken at two different layers (0.00–0.05 and 0.05–0.20 m) for chemical, physical, and organic matter characterization. C inputs monitored in aboveground pools included plant aerial parts and litter, and belowground pools included roots and soil C stocks. C outputs monitored were CO2–C emissions, erosion water, and sediment. C balance was considered the difference between inputs and outputs in each treatment during four seasons. The spring and summer seasons had a strong influence on C inputs and outputs where there is significant difference between spring and summer, while the autumn and winter seasons had less influence. All pasture management practices exhibited positive C balance after 1 year. High values of C balance were verified in pastures fertilized (FER) (53.04 Mg ha−1 year−1. Intermediate C balance was found in the burned (BUR) (40.84 Mg ha−1 year−1), traditional control (CON) (40.31 Mg ha−1 year−1), and in the plowing and harrowing (PH) (40.02 Mg ha−1 year−1) management practices. The practices of chiseled (40.00 Mg ha−1 year−1) and integrated crop–livestock systems (iCL) (59.06 Mg ha−1 year−1) resulted in low C balance.

SummaryBackground: The ability to manage and leverage family history information in the electronic health record (EHR) is crucial to delivering high-quality clinical care.Objectives: We aimed to evaluate existing standards in representing relative information, examine this information documented in EHRs, and develop a natural language processing (NLP) application to extract relative information from free-text clinical documents.Methods: We reviewed a random sample of 100 admission notes and 100 discharge summaries of 198 patients, and also reviewed the structured entries for these patients in an EHR system’s family history module. We investigated the two standards used by Stage 2 of Meaningful Use (SNOMED CT and HL7 Family History Standard) and identified coverage gaps of each standard in coding relative information. Finally, we evaluated the performance of the MTERMS NLP system in identifying relative information from free-text documents.Results: The structure and content of SNOMED CT and HL7 for representing relative information are different in several ways. Both terminologies have high coverage to represent local relative concepts built in an ambulatory EHR system, but gaps in key concept coverage were detected; coverage rates for relative information in free-text clinical documents were 95.2% and 98.6%, respectively. Compared to structured entries, richer family history information was only available in free-text documents. Using a comprehensive lexicon that included concepts and terms of relative information from different sources, we expanded the MTERMS NLP system to extract and encode relative information in clinical documents and achieved a corresponding precision of 100% and recall of 97.4%.Conclusions: Comprehensive assessment and user guidance are critical to adopting standards into EHR systems in a meaningful way. A significant portion of patients’ family history information is only documented in free-text clinical documents and NLP can be used to extract this information.Citation: Zhou L, Lu Y, Vitale CJ, Mar PL, Chang F, Dhopeshwarkar N, Rocha RA. Representation of information about family relatives as structured data in electronic health records. Appl Clin Inf 2014; 5: 349–367 http://dx.doi.org/10.4338/ACI-2013-10-RA-0080

OBJETIVO: avaliar a eficácia da complementação por coagulação com plasma de argônio para reduzir a taxa de neoplasia residual ou recorrente após ressecção endoscópica completa fragmentada de grandes adenomas sésseis colorretais. MÉTODOS: critérios de inclusão: pacientes com grandes adenomas colorretais sésseis, > 20mm, sem sinais morfológicos de infiltração profunda, submetidos à ressecção endoscópica completa fragmentada estudada com cromoendoscopia e magnificação de imagens. Os pacientes foram randomizados em dois grupos: grupo 1 - nenhum procedimento adicional e, grupo 2 - complementação por coagulação com plasma de argônio. O seguimento por colonoscopia foi realizado em três, seis e 12 meses de pós-operatório. Foi avaliada a taxa de neoplasia residual ou recidiva local. RESULTADOS: foram incluídos no estudo um total de 21 lesões. Onze lesões no grupo 1 e dez no grupo 2. Ocorreram duas neoplasias residuais ou recorrências locais em cada grupo, detectadas em três meses de acompanhamento. CONCLUSÃO: a complementação por coagulação com plasma de argônio após uma aparente ressecção endoscópica completa em fragmentos de grandes adenomas sésseis colorretais não parece reduzir a ocorrência de lesão adenomatosa residual ou recidiva local. OBJECTIVE: To evaluate the efficacy of complement by argon plasma coagulation to reduce the rate of residual or recurrent tumor after complete endoscopic piecemeal resection of large sessile colorectal adenomas. METHODS: Inclusion criteria: patients with large sessile colorectal adenomas (e" 20 mm), without morphological signs of deep infiltration, submitted to complete endoscopic piecemeal resection studied with chromoendoscopy and magnification of images. Patients were randomized into two groups: group 1 - no additional procedure, and group 2 - complementation by argon plasma coagulation. follow-up colonoscopy was performed at three, six and 12 months postoperatively. We evaluated the rate of local recurrence or residual malignancy. RESULTS: The study included 21 patients, eleven in group 1 and ten in group 2. There were two local recurrences or residual tumors in each group, detected at three months follow-up. CONCLUSION: Complementation by argon plasma coagulation after apparent complete endoscopic piecemeal resection of large sessile colorectal adenomas does not seem to reduce the occurrence of residual adenomatous lesions or local recurrence.

Objective Allergy documentation and exchange are vital to ensuring patient safety. This study aims to analyze and compare various existing standard terminologies for representing allergy information. Methods Five terminologies were identified, including the Systemized Nomenclature of Medical Clinical Terms (SNOMED CT), National Drug File–Reference Terminology (NDF-RT), Medication Dictionary for Regulatory Activities (MedDRA), Unique Ingredient Identifier (UNII), and RxNorm. A qualitative analysis was conducted to compare desirable characteristics of each terminology, including content coverage, concept orientation, formal definitions, multiple granularities, vocabulary structure, subset capability, and maintainability. A quantitative analysis was also performed to compare the content coverage of each terminology for (1) common food, drug, and environmental allergens and (2) descriptive concepts for common drug allergies, adverse reactions (AR), and no known allergies. Results Our qualitative results show that SNOMED CT fulfilled the greatest number of desirable characteristics, followed by NDF-RT, RxNorm, UNII, and MedDRA. Our quantitative results demonstrate that RxNorm had the highest concept coverage for representing drug allergens, followed by UNII, SNOMED CT, NDF-RT, and MedDRA. For food and environmental allergens, UNII demonstrated the highest concept coverage, followed by SNOMED CT. For representing descriptive allergy concepts and adverse reactions, SNOMED CT and NDF-RT showed the highest coverage. Only SNOMED CT was capable of representing unique concepts for encoding no known allergies. Conclusions The proper terminology for encoding a patient's allergy is complex, as multiple elements need to be captured to form a fully structured clinical finding. Our results suggest that while gaps still exist, a combination of SNOMED CT and RxNorm can satisfy most criteria for encoding common allergies and provide sufficient content coverage.

Plastic Surgery Division, Universidade do Vale do Sapucai—UNIVAS, Rua Comendador Jose Garcia, 777, CEP 37550-000, Pouso Alegre, MG, Brazil

SummaryBackground: Site-specific content configuration of vendor-based Electronic Health Records (EHRs) is a vital step in the development of standardized and interoperable content that can be used for clinical decision-support, reporting, care coordination, and information exchange. The multi-site, multi-stakeholder Acute Care Documentation (ACD) project at Partners Healthcare Systems (PHS) aimed to develop highly structured clinical content with adequate breadth and depth to meet the needs of all types of acute care clinicians at two academic medical centers. The Knowledge Management (KM) team at PHS led the informatics and knowledge management effort for the project.Objectives: We aimed to evaluate the role, governance, and project management processes and resources for the KM team’s effort as part of the standardized clinical content creation.Methods: We employed the Center for Disease Control’s six step Program Evaluation Framework to guide our evaluation steps. We administered a forty-four question, open-ended, semi-structured voluntary survey to gather focused, credible evidence from members of the KM team. Qualitative open-coding was performed to identify themes for lessons learned and concluding recommendations.Results: Six surveys were completed. Qualitative data analysis informed five lessons learned and thirty specific recommendations associated with the lessons learned. The five lessons learned are: 1) Assess and meet knowledge needs and set expectations at the start of the project; 2) Define an accountable decision-making process; 3) Increase team meeting moderation skills; 4) Ensure adequate resources and competency training with online asynchronous collaboration tools; 5) Develop focused, goal-oriented teams and supportive, consultative service based teams.Conclusions: Knowledge management requirements for the development of standardized clinical content within a vendor-based EHR among multi-stakeholder teams and sites include: 1) assessing and meeting informatics knowledge needs, 2) setting expectations and standardizing the process for decision-making, and 3) ensuring the availability of adequate resources and competency training.Citation: Collins SA, Bavuso K, Zuccotti G, Rocha RA. Lessons learned for collaborative clinical content development Appl Clin Inf 2013; 4: 304–316http://dx.doi.org/10.4338/ACI-2013-02-CR-0014

OBJECTIVES: To compare the efficacy and safety of two filgrastim formulations for controlling chemotherapy-induced neutropenia and to evaluate the non-inferiority of the test drug relative to the originator. METHODS: This phase III non-inferiority study had a randomized, multicenter, and open-label design. The patients were randomized at a ratio of 1:1 with a follow-up period of 6 weeks for each patient. In both study arms, filgrastim was administered subcutaneously at a daily dose of 5 mg/kg body weight. The primary endpoint was the rate of grade 4 neutropenia in the first treatment cycle. The secondary endpoints were the duration of grade 4 neutropenia, the generation of anti-filgrastim antibodies, and the rates of adverse events, laboratory abnormalities, febrile neutropenia, and neutropenia of any grade. RESULTS: The primary efficacy analysis demonstrated the non-inferiority of the test drug compared with the originator drug; the upper limit of the 90% confidence interval (CI) for the rate of neutropenia between the two groups (12.61%) was lower than the established margin of non-inferiority. The two treatments were similar with respect to the secondary endpoints and safety. CONCLUSION: The efficacy and safety profile of the test drug were similar to those of the originator product based on the rate of grade 4 neutropenia in the first treatment cycle. This study supports Anvisa’s approval of the first biosimilar drug manufactured by the Brazilian industry (Fiprima¯).

The medical community within the United States is adopting Electronic Health Records (EHRs) at an accelerating pace. These systems are designed to support medical documentation, communication, and billing practices and can bring the efficiencies of digital systems to these healthcare functions. However, one of the key advantages of an EHR is the availability of cognitive support provided during the care process in the form of embedded Clinical Decision Support Systems (CDSS). Historically, the initial exploration of CDS technologies occurred in a group of hospital-based EHRs. These pioneering institutions engaged in early experimentation with a variety of CDS interventions. In this chapter, we describe experience with a group of CDS applications developed and evaluated within the HELP Hospital Information System created and used by Intermountain Healthcare of Utah. These CDS applications have employed several different approaches in their interactions with clinical users and their capture and processing of clinical data.

Graphical abstractDisplay Omitted Highlights? We mapped Partners Master Drug Dictionary (MDD) to RxNorm. ? 74.7% of MDD terms had an exact semantic match to RxNorm. ? Natural language processing tool achieved a precision of 99.8% and a recall of 73.9%. ? Multiple challenges and gaps in mapping were identified. ? NLP tool followed by manual review is efficient for drug terminology mapping. ObjectiveTo develop an automated method based on natural language processing (NLP) to facilitate the creation and maintenance of a mapping between RxNorm and a local medication terminology for interoperability and meaningful use purposes. MethodsWe mapped 5961 terms from Partners Master Drug Dictionary (MDD) and 99 of the top prescribed medications to RxNorm. The mapping was conducted at both term and concept levels using an NLP tool, called MTERMS, followed by a manual review conducted by domain experts who created a gold standard mapping. The gold standard was used to assess the overall mapping between MDD and RxNorm and evaluate the performance of MTERMS. ResultsOverall, 74.7% of MDD terms and 82.8% of the top 99 terms had an exact semantic match to RxNorm. Compared to the gold standard, MTERMS achieved a precision of 99.8% and a recall of 73.9% when mapping all MDD terms, and a precision of 100% and a recall of 72.6% when mapping the top prescribed medications. ConclusionThe challenges and gaps in mapping MDD to RxNorm are mainly due to unique user or application requirements for representing drug concepts and the different modeling approaches inherent in the two terminologies. An automated approach based on NLP followed by human expert review is an efficient and feasible way for conducting dynamic mapping.

The present work studied the adsorption of ions of iron and manganese of the effluent from coal acid mine drainage (AMD), located in South of the Santa Catarina using for this purpose type 4A zeolite. Were tested the Langmuir adsorption isothermal model. Tests of adsorption of heavy metals were performed by varying the adsorption time and the ratio of the volume of effluent and the amount of adsorbent. The results showed the efficiency of kinetic adsorption of iron and manganese ions by the zeolite.

Research focused on the transformation and utilization of industrial wastes into products of commercial interest plays an increasingly important role. Residual pulp can become useful in the manufacture of different materials, providing high value to this waste and reducing its environmental impact when disposed of improperly in the environment. The main constituents of this waste are kaolin and calcium carbonate (CaCO3). Starting from kaolin, metakaolin can be produced by calcination of the residue at 630 °C for 2 h in a rotary reactor with air flow, followed by solubilization with hydrochloric acid to remove the CaCO3. The development of technological alternatives aimed at the reuse of certain wastes can result in applications of real economic interest to the chemical industry and ceramics and glass, which is the case in this study. The raw material and metakaolin obtained were analyzed by thermogravimetric analysis and derivative thermogravimetric analysis, X-ray diffraction, and X-ray fluorescence spectroscopy with promising results. This is because metakaolin was obtained free of contamination by other materials.

Standard surgical procedures used for the treatment of morbid obesity constitute optional treatments for type 2 diabetes mellitus (T2DM). The aim of the present study was to evaluate the short- and mid-term effects of laparoscopic sleeve gastrectomy (SG) with ileal interposition (II) in T2DM patients (n = 30). The variables investigated were the feasibility of the procedure, remission/alleviation of the disease, morbidity, mortality, and weight loss. Patients were followed during a period of 6–18 months after surgery. The average time required for the surgical procedure was 181.47 ± 53.23 min, and the mean duration of postoperative hospital stay was 3.17 ± 0.79 days. There were no intraoperative complications, and none of the patients required conversion to open surgery. Postoperatively, all patients experienced a significant weight loss: i.e., the mean body mass index (BMI) values prior to and following surgery were significantly different (P = 0.0001). Postoperative levels of glycosylated hemoglobin, fasting glucose, and fructosamine were significantly reduced (P = 0.0001, 0.0001, and 0.0004, respectively) from those detected prior to surgery. Remission of T2DM was observed in 80% of the patients over the follow-up period, and these subjects no longer required treatment with hypoglycemic drugs or diet. The remaining 20% of patients presented significant improvement in their condition but needed an oral hypoglycemic medication. Adequate glycemic control, adjustable weight loss, and absence of nutritional deficiencies were the main benefits offered by the surgical intervention. The results indicate that SG/II treatment could be a promising alternative for patients with T2DM.

A small scale documentation analysis was conducted to explore the medical and surgical nursing content of the patient record at a large teaching hospital affiliated with Partners Healthcare System (PHS), in preparation for a computerized documentation system. Through this study, we identified a number of problems associated with the paper record that require resolution in the new computerized system, including elimination of documentation redundancy, areas where more structure is needed to properly capture data on nursing practice, and various design considerations to support a more complete and accurate documentation of nursing care.

Provision of query systems which are intuitive for non-experts has been recognized as an important informatics challenge. We developed a prototype of a flowchart-based analytical framework called RetroGuide that enables non-experts to formulate query tasks using a step-based, patient-centered paradigm inspired by workflow technology. We present results of the evaluation of RetroGuide in comparison to Structured Query Language (SQL) in laboratory settings using a mixed method design. We asked 18 human subjects with limited database experience to solve query tasks in RetroGuide and SQL, and quantitatively compared their test scores. A follow-up questionnaire was designed to compare both technologies qualitatively and investigate RetroGuide technology acceptance. The quantitative comparison of test scores showed that the study subjects achieved significantly higher scores using the RetroGuide technology. Qualitative study results indicated that 94% of subjects preferred RetroGuide to SQL because RetroGuide was easier to learn, it better supported temporal tasks, and it seemed to be a more logical modeling paradigm. Additional qualitative evaluation results, based on a technology acceptance model, suggested that a fully developed RetroGuide-like technology would be well accepted by users. Our study is an example of a structure validation study of a prototype query system, results of which provided significant guidance in further development of a novel query paradigm for EHR data. We discuss the strengths and weakness of our study design and results, and their implication for future evaluations of query systems in general.

The systematic collection and organization of routine medical care data, together with data mining techniques, offer a rich environment for valuable, large-scale observational studies. We report on one such study in the context of bariatric surgery, where we build predictive models for surgical procedure selection and overall success of surgery. We suggest that observational studies supported by predictive informatics may usefully complement classical clinical trials in medical research.

Aims The objective of this work was to evaluate the acute toxicity of long-circulating and pH-sensitive liposomes containing cisplatin (SpHL-CDDP), after their intraperitoneal administration in male and female mice. Main methods After single administration of free CDDP (5,10,and 20 mg/kg) or SpHL-CDDP (7,12,30,45 and 80 mg/kg), the body weight was recorded and the LD 50 was calculated. Blood samples were collected for biochemical and hematological analysis. Kidneys, liver, spleen and bone marrow were removed to histopathological examination. Key findings Mice treated with high doses of free CDDP showed a greater loss of body weight and more delayed recovery time than those treated with SpHL-CDDP. The LD 50 values for SpHL-CDDP treatment for male and female mice groups were 2.7 and 3.2 fold higher, respectively, than that obtained for free CDDP. The red and white blood cells counts and quantification of hemoglobin and hematocrit presented no change upon administration of SpHL-CDDP treatment. Free CDDP treatment, however, did lead to an appearance of mild anemia and a reduction in total white blood cell counts. As regards nephrotoxicity, it was observed that free CDDP treatment caused pronounced alterations in the blood urea and creatinine levels of mice. In contrast, these parameters were slightly altered only after SpHL-CDDP treatment at a dose of 30 mg/kg. Microscopic analysis of kidneys from mice treated with SpHL-CDDP showed no morphological alteration. Concerning hepatotoxicity, no histopathological alteration was observed after both treatments. Significance These findings reveal that SpHL-CDDP can eliminate CDDP-induced toxicity and is thus a promising candidate for intraperitoneal chemotherapy.

The aim of this work is the production of a simple and compactable device able to remove hydrocarbons from a gaseous sample. The device is composed of a microstructure, inlet/outlet, heating and detection systems. The microstructure (microreactor) corresponds to a manifold formed by an array of 192 three-dimensional microchannels, 40 μm wide and 8 mm long each. Microchannels surface was modified by electroless plating copper deposition in order to promote catalysis. The structure can be heated up to 300 °C in a few seconds. The flow mechanisms in the structure and the heating properties were simulated using FEMLAB 3.2b and COSMOS ® 5.0 packages, respectively. The microchannels were exposed to volatile organic compounds during catalysis. An inexpensive tin oxide sensor and correspondent electronic coupled to computer storage data provided detection. Catalysis occurred and could remove at least 10 μg of n-hexane in a single batch, but not 2-propanol. This simple miniaturized device is compact, low-cost and can be used not only for sample pretreatment in microanalysis but also in synthesis of new chemical compounds.

The effects of vertical banded gastroplasty/Roux-en-Y gastric bypass (Capella) on the esophageal mucosa of patients with histological esophagitis are poorly understood. To evaluate long-term effects, we investigated the persistence, aggravation or disappearance of histological esophagitis in patients with morbid obesity and reflux esophagitis (diagnosed by endoscopic biopsy) after Roux-en-Y gastric bypass.Twenty-one patients with morbid obesity and esophagitis (histological diagnosis) were submitted to gastric bypass (Fobi-Capella technique) and underwent upper endoscopy and esophageal biopsy during the late postoperative period.The mean age of the patients was 42.57 +/- 7.49 years (30 to 56). Nineteen (90.48%) patients were women, and two (9.52%) were men. Before surgery, the patients presented a mean weight of 124.26 +/- 19.09 kg and a mean body mass index (BMI) of 48.46 +/- 6.37 kg/m(2). Thirteen (61.90%) patients had endoscopic esophagitis before surgery. The mean weight and BMI were 81.65 +/- 13.16 kg and 31.91 +/- 4.99 kg/m(2), respectively, during the late postoperative period (29.80 +/- 8.91 months). The mean percentage of excess weight loss was 68.7 +/- 14.6%. Among the 21 patients with a preoperative histological diagnosis of reflux esophagitis, five (23.18%) had the same diagnosis after surgery, and four (19.04%) continued to present findings of endoscopic esophagitis.Vertical banded gastroplasty/Roux-en-Y gastric bypass (Capella technique) is effective in the treatment of reflux esophagitis. No association was observed between the percentage of excess weight loss and improvement of esophagitis.

Objective: We have developed an automated knowledge base peer feedback system as part of an effort to facilitate the creation and refinement of sound clinical knowledge content within an enterprise-wide knowledge base. The program collects clinical data stored in our Clinical Data Repository during usage of a physician order entry program. It analyzes usage patterns of order sets relative to their templates and creates a report detailing the usage patterns of the order set template. This report includes a set of suggested modifications to the template. Design: A quantitative analysis was performed to assess the validity of the program's suggested order set template modifications. Measurements: We collected and deidentified 2951 instances of POE-based orders. Our program then identified and generated feedback reports for thirty different order set templates from this data set. These reports contained 500 suggested modifications. Five order set authors were then asked to 'accept' or 'reject' each suggestion contained in his/her respective order set templates. They were also asked to categorize their rationale for doing so ('clinical relevance' or 'user convenience'). Results: In total, 62% (309/500) suggestions were accepted by clinical content authors. Of these, authors accepted 32% (36/114) of the suggested additions, 74% (123/167) of the suggested pre-selections, 76% (16/25) of the suggested de-selections, and 68% (131/194) of the suggested changes in combo box order. Conclusion: Overall, the feedback system generated suggestions that were deemed highly acceptable among order set authors. Future refinements and enhancements to the software will add to its utility.

Esophagogastroduodenoscopy (EGD) is frequently requested for patients with gastroesophageal reflux symptoms. When the distal esophagus mucosa shows no erosions, questions are posed: (1) Does the esophageal biopsy contribute to confirm reflux as the cause of the symptoms? (2) Do minimum endoscopic changes have correspondence with histology? A total of 1901 patients were prospectively interviewed by a standard questionnaire to obtain a clinical diagnosis of gastroesophageal reflux disease (GERD); 150 patients (98 males; median age, 42 years) with clinical manifestations of GERD and an intact esophageal mucosa were assigned to nonerosive reflux disease (NERD) patients, and 49 patients (24 males; median age, 46 years) with no complaints of GERD were assigned to Controls. The EGD images were documented on tape. Four biopsies were performed at the distal esophagus. Experienced endoscopists and pathologists examined twice, at different times and separately, the respective endoscopic and histological examinations. For all comparisons, kappa (K) match, 95% confidence interval, and the P value were determined. In NERD patients, the match between endoscopic and histological findings as to the aspect of the mucosa of the esophagus was poor (K = 0.08). EGD showed 17.2% sensitivity and 90.2% specificity, whereas the esophagus histological study showed 39% sensitivity and 73% specificity. NERD patients presented a greater frequency of esophagitis than Controls (38.6% vs. 22.4%), but this value was nonsignificant (P = 0.023). Agreement between patient symptoms or endoscopic findings and histological diagnosis is poor; therefore, histology of the esophageal mucosa as a diagnostic test of NERD demonstrates low sensitivity and does not justify routine use.

It has been suggested that obesity is associated with an altered rate of gastric emptying. The objective of the present study was to determine whether the rates of solid and semi-solid gastric emptying differ between morbidly obese patients and lean subjects. The Gastric-emptying time (GET) of solid and semi-solid meals were compared between lean healthy subjects and morbidly obese patients enrolled in two previously published studies. GET of solid and semi-solid meals was measured using the 13C-octanoic acid breath test and 13C-acetic acid breath test, respectively, in 24 lean and 14 morbidly obese individuals of both sexes. Student t-test was used to compare the mean data between the lean and morbidly obese groups. The influence of sex, gender, BMI and morbid obesity on the GET of solid meals was verified by linear regression analysis. Mean t(1/2) values of solid GET (± standard deviation) were 203.6 ± 76.0 min and 143.5 ± 19.1 min for lean and obese subjects, respectively (P = 0.0010). Mean t(lag) values of solid GET were 127.3 ± 42.7 min and 98.4 ± 13.0 min for lean and obese subjects, respectively (P = 0.0044). No significant difference in semi-solid GET was observed between the lean and morbidly obese groups. The present study demonstrated a significantly enhanced gastric emptying of the solid meal test in morbidly obese patients when compared to lean subjects. This finding is compatible with the hypothesis that rapid gastric emptying in morbidly obese subjects increases caloric intake due to a more rapid loss of satiety.

Background: Obesity represents a major public health problem in western countries. Initial studies suggest that injection of botulinum A toxin (Btx-A) into the antropyloric region inhibits propulsive contractions of the antral pump, with delay in gastric emptying, early satiety and weight loss. Methods: After approval by the University Ethics Committee, we prospectively evaluated 12 patients with class III obesity divided into 4 groups of 3 patients each. In groups I and II, 200 U Btx-A were injected into the antropyloric region at 8 and 16 sites, respectively. Groups III and IV received 300 U Btx-A into the antropyloric region at 16 and 24 sites, respectively. Body weight and gastric emptying time (GET) of solids and semi-solids using 13C-octanoic acid breath test and 13C-acetic acid breath test, respectively, were determined before and after injection over a period of 12 weeks. Results: Pre- and post-treatment body weight or solid and semi-solid GET did not differ significantly between groups (P>0.05). All patients reported a feeling of early satiety. No adverse effects related to BtxA or complications resulting from the endoscopic procedure were observed. Conclusion: The injection of different doses of BtxA at different sites in the antropyloric region of patients with class III obesity did not interfere significantly with the solid and semi-solid GET or body weight of these individuals. However, early satiety was reported by all patients, the procedure was safe and no side-effects of the treatment were observed. Further controlled studies involving different methodologies regarding dosage of Btx-A and sites of injection are necessary.

Summary Objectives: Knowledge bases comprise a vital component in the classic medical expert system model, yet the knowledge acquisition process by which they are created has been characterized as highly iterative and labor-intensive. The difficulty of this process underscores the importance of knowledge authoring tools that satisfy the demands of end-users. The authors hypothesize that the acceptability of a knowledge authoring tool for the creation of medical knowledge base content can be predicted by an accepted model in the information technology (IT) field, specifically the Technology Acceptance Model (TAM). Methods: An online survey was conducted amongst knowledge base authors who had previously established experience with the authoring tool software. The Likert-based questions in the survey were patterned directly after accepted TAM constructs with minor modifications to particularize them to the software being used. The results were analyzed using structural equation modeling. Results: The TAM performed well in predicting end-users’ behavioral intentions to use the knowledge authoring tool. Five out of seven goodness-of-fit statistics indicate that the model represents the behavioral intentions of the authors well. All but one of the hypothesized relationships specified by the TAM were significant with p values less than 0.05. Conclusions: The TAM provides an adequate means by which development teams can anticipate and better understand what aspects of a knowledge authoring tool are most important to their target audience. Further research involving other behavioral models and an expanded user base will be necessary to better understand the scope of issues that factor into acceptability.

As part of an enterprise effort to develop new clinical information systems at Intermountain Health Care, the authors have built a knowledge authoring tool that facilitates the development and refinement of medical knowledge content. At present, users of the application can compose order sets and an assortment of other structured clinical knowledge documents based on XML schemas. The flexible nature of the application allows the immediate authoring of new types of documents once an appropriate XML schema and accompanying Web form have been developed and stored in a shared repository. The need for a knowledge acquisition tool stems largely from the desire for medical practitioners to be able to write their own content for use within clinical applications. We hypothesize that medical knowledge content for clinical use can be successfully created and maintained through XML-based document frameworks containing structured and coded knowledge.

Background: The authors evaluated calcium metabolism in obese women, before and after menopause, at baseline and at 6 and 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGBP). LRYGBP restricts food intake and produces physiological changes that may be similar to those after high Billroth II subtotal gastrectomy. Methods: Serum calcium (Ca), phosphate, bone-specific alkaline phosphatase (BSAP) and 25-hydroxyvitamin D3 (25-OH D) were measured at baseline and 12 months after LRYGBP. Urinary N-telopeptide (u-NTX) was measured at baseline and serum C-telopeptide (s-CTX) at 6 and 12 months after LRYGBP. Parathormone (PTH) was measured at baseline and 6 and 12 months after LRYGBP. Patients were divided into 2 groups: Group I (n=30) pre-menopausal women aged 18-42 y, and Group II (n=30) post-menopausal women aged 40-71 y. Patients with renal, hepatic, metabolic and bone disease, smoking women, as well as patients with u-NTX values at baseline >67 nMBCE/mMCr were excluded. Results: At baseline, PTH was elevated in 10% of patients in each group, correlated positively with BMI, and low serum calcium values were found in 30% of Group I and 16.7% of Group II. High values of serum C-telopetide were seen in Group I at 6 months after surgery and in Group II 12 months after LRYGBP. Group II showed a greater increase in BSAP at 12 months after LRYGBP. 25-0H D decreased in both groups, and a progressive increase in PTH was observed. Serum calcium did not change in both groups. Conclusion: Calcium metabolism is altered in pre- and post-menopausal women following LRYGBP. Calcium and vitamin D supplementation is strongly advised in all patients.

A computerized provider order entry (CPOE) system can provide an efficient means of retrieving and consolidating order lists from multiple electronic clinical practice standards and protocols. However, the consolidated order list may contain exact duplicate or overlapping orders. Benner's framework for levels of nursing expertise can be used to explicate the variability of the nurse's responses to redundancies in order lists and the potential compromise to patient safety. An exploratory case method was performed to consolidate 74 orders from 11 sources. The consolidated order list contained 35% fewer orders after the redundant orders were removed. Our work has shown that many redundant orders may arise by consolidating order lists from multiple electronic standards. It is imperative that consolidated electronic order lists be manageable by the nurse according to their level of clinical and computer expertise, and that redundant orders are resolved before being displayed to the nurse.

Objective:This study compared the incidence of salivary fistula between groups with an early or late reintroduction of oral feeding, and identified the predictive factors for salivary fistula.Methods:A randomised trial was performed using 89 patients with larynx or hypopharynx cancer, assigned to 2 groups (early or late). In the early group, oral feeding was started 24 hours after total laryngectomy or total pharyngolaryngectomy, and in the late group, it was started from post-operative day 7 onwards. The occurrence of salivary fistula was evaluated in relation to the following variables: early or late oral feeding, nutritional status, cancer stage, surgery performed, and type of neck dissection.Results:The incidence of salivary fistula was 27.3 per cent (n = 12) in the early group and 13.3 per cent (n = 6) in the late group (p = 0.10). The following variables were not statistically significant: nutritional status (p = 0.45); tumour location (p = 0.37); type of surgery (p = 0.91) and type of neck dissection (p = 0.62). A significant difference (p = 0.02) between the free margins and invasive carcinoma was observed.Conclusion:The early reintroduction of oral feeding in total laryngectomised patients did not increase the incidence of salivary fistula.

This chapter presents a complete program for clinical knowledge management from an institutional perspective, including motivation, requirements, and implementation strategies. The knowledge engineering process and the knowledge asset lifecycle are also discussed, taking into account extensible modeling approaches that ensure consistent knowledge representation and effective collaboration. Special emphasis is given to requirements for a comprehensive software infrastructure to support the knowledge management program and enable effective integration with clinical information systems. New opportunities and challenges related to personalized clinical decision support interventions and advanced curation tools are also outlined, taking into account inter-institutional collaborations leading to a sustainable exchange of knowledge assets. The chapter concludes with a brief overview of the ongoing program implementation efforts at Partners HealthCare.