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Objective To identify how health providers recognize postpartum hemorrhage early and the difficulties involved in it. Methods An exploratory, descriptive study using a qualitative approach through a semi-structured interview technique. In total, 27 health professionals (nursing tech nicians, nurses, medical residents in Gynecology and Obstetrics, hired medical doctors, and medicine professors) working in a tertiary-level hospital of reference in women’s health care in the State of São Paulo, Brazil, participated in the study through an invitation. After they accepted the invitation, they signed the free and informed consent form. All interviews were recorded and transcribed, and a thematic analysis was conducted. We found three analysis categories: a) perception of the severity: “there is something wrong with the women”; b) difficulties in the early diagnosis of postpartum hemorrhage; and c) the process to improve obstetrical care. Results Caregivers believe teamwork and communication should be improved. Besides the visual estimation of blood loss, the nursing team is attentive to behavioral symptoms like irritability, while the medical staff follow protocols and look for objective signs, such as altered vital signs. Conclusion Besides the objective evaluations, the subjective perceptions of the providers are involved in the clinical judgement regarding the diagnosis of postpartum hemorrhage, and this should be included in a broader diagnosis strategy. Resumo Objetivo Identificar como os profissionais de saúde reconhecem precocemente os casos de hemorragia pós-parto e as suas dificuldades. Métodos Realizou-se um estudo exploratório, descritivo, com uma abordagem qualitativa por meio da técnica de entrevista semiestruturada. Por meio de um convite, participaram do estudo 27 profissionais saúde (técnicas de enfermagem, enfermeiras, residentes de Ginecologia e Obstetrícia, e médicos contratados e docentes) que trabalhavam em um hospital de nível terciário de referência no atendimento à saúde da mulher no estado de São Paulo. Depois que os participantes aceitaram o convite, eles assinaram o termo de consentimento livre e esclarecido. Todas as entrevistas foram gravadas, transcritas, e realizou-se uma análise temática. Identificaram-se três categorias de análise: a) percepção da gravidade: “há algo de errado com as mulheres”; b) dificuldades no diagnóstico precoce da hemorragia pós-parto; e c) o processo para melhorar a atenção em obstetrícia. Resultados Os profissionais de saúde acreditavam que o trabalho em equipe e a comunicação deviam ser aperfeiçoados. Além da estimativa visual da perda de sangue, a equipe de enfermagem estava atenta a sintomas comportamentais como irritabilidade, ao passo que o pessoal médico seguia protocolos e procurava sinais objetivos, como sinais vitais alterados. Conclusão Além das avaliações objetivas, as percepções subjetivas dos provedores estão envolvidas no julgamento clínico do diagnóstico de hemorragia pós-parto, e isto deve ser incluído em uma estratégia de diagnóstico mais ampla.

Appropriate use criteria (AUC) are statements that contain indications describing when and how often an intervention should be performed under the optimal combination of scientific evidence, clinical judgment, and patient values while avoiding unnecessary provisions of services. Society of Nuclear

Pressure injuries (PIs) are a global health concern. Current PI care standards, including skin tissue assessments (STA) and health care professional (HCP) clinical judgment, diagnose visibly manifested PIs on the skin's surface, i.e. after the damage has already occurred. However, objective assessment of early-stage, non-visible, pressure-induced tissue damage is clinically impossible within the current standard of care. The SEM Scanner is the first device authorized by the Food and Drug Administration (FDA) that addresses this unmet clinical need.This review describes the novel sub-epidermal moisture (SEM) scanning technology of the device and summarizes the clinical safety and efficacy data that support the use of the scanner in routine PI care practice.The clinical strategy for developing the SEM Scanner is noteworthy. SEM technology using anatomy-specific data enables HCPs to provide early PI prevention interventions before visible signs of tissue damage develop while the damage is still reversible. When adopted into routine practice, the device identifies an increased risk of developing PIs 5 days (median) earlier than STA. FDA clearance was based on bench studies and data from three foundational trials that demonstrate the diagnostic accuracy of the device algorithm significantly exceeding clinical judgment (p 0.001).

Back in 1974, in an effort to engage residents in research, senior residents were asked to identify the clinical activity they found most frustrating. They responded, “Having to do complete sepsis work-ups on young infants just because they are febrile. Practitioners don’t do that, and we can tell when infants are septic or not.” This prompted a study to determine how well the clinical judgment of senior residents, supplemented by complete blood cell counts and cerebrospinal fluid (CSF) analyses, performed in the evaluation of febrile infants 0 to 8 weeks of age. It was the heyday of group B streptococcal infections, as reflected in the bacteremia rate of 14.8% in the 62 consecutively enrolled infants studied.1 Infants classified as “ill” or “can’t tell” had rates of 18.5% and 18.8%, respectively, whereas the rate in infants classified as “well” was 5.6%, 1 of 18 infants. The study was small, to be sure, but that was not the major impediment to publication. Journal peer reviewers could not understand why such a study was performed because it was common knowledge that clinical judgment did not apply to very young febrile infants. Other similar studies followed2,3 along with the recognition of iatrogenic complications associated with hospitalizing these infants.4 By the mid-1980s, there was sufficient confirmation that, although well-appearing febrile infants had a lower rate of bacteremia than those who were ill-appearing, the rate was not 0, and infants with bacteremia could not be distinguished with complete certainty from those without bacteremia. Then Keith Powell and his colleagues at Rochester proposed an alternative strategy: instead of focusing on who had bacteremia, focus on those who did not and create criteria for a low-risk category that could permit infants to avoid unnecessary (over)treatment. Thus, the Rochester criteria were born,5 followed …

Artificial intelligence (AI) and machine learning refer to computers built and programed by humans to perform tasks according to our design. This is vital to keep in mind as we try to understand the application of AI to medicine. AI is a tool with strengths and limitations. The primary strength of AI is that it allows us to assimilate and process unlimited quantities of health care data. The limits of AI include the inability of machines to adapt in a human sense, the reality that machines lack human insight (i.e., clinical judgment or common sense), and the limitation that machine-learning algorithms are subject to the data on which they are trained. Thus, we must adapt to AI and machine learning. Next, because machine learning is a type of AI in which computers are programmed to improve the algorithms under which they function over time, we require insight to achieve an element of explainability about the key data underlining a particular machine-learning prediction. Finally, machine-learning algorithms require validation before they can be applied to data sets different from the data on which they were trained. As computers have become faster and more powerful, and as the availability of digital data has become immense, we can program our machines to analyze data and recognize patterns that, in sum, are a primary basis of medical diagnosis and treatment.

Frenuloplasty is a common surgical procedure performed on an outpatient basis either for the treatment of frenulum breve alone or as an additional intervention in patients undergoing circumcision. We aimed to provide tips and tricks on performing frenuloplasty, either alone or in combination with circumcision, and to generate a comprehensive review of the available literature on the matter. We suggest that the frenulum should be divided with a scalpel without the use of diathermy and reapproximated with interrupted 4-0 absorbable sutures. Moreover, the frenular artery should be maintained and any injury of the glans must be avoided to ensure optimal functional outcomes. After the procedure, a paraffin gauze filled with antibiotic paste followed by a light compression dressing for one day should be placed to maximize cosmetic results. Regarding the available literature, several methods of frenuloplasty have been described, varying from simple division of the frenulum to more sophisticated grafting or plasty techniques. Both the use of diathermy and the application of laser, with or without suturing of the released frenulum, seem to provide optimal functional and esthetic results. However, the findings of all available studies were mitigated by the relatively small number of included participants and low response rates. Additionally, comparative data or high-quality, long-term functional and cosmetic results on the matter are lacking. Therefore, until high-level evidence regarding frenuloplasty is available, individual clinical judgment should prevail.

Aim This two-group feasibility study tested the efficacy of a four-scenario simulation program to improve clinical judgment and clinical competence among graduate nurses. Background Clinical judgment and clinical competence are underdeveloped among new-to-practice nurses. Method Clinical judgment was compared between the intervention group (n = 17) and a control group (n = 26) in the practice setting at two time points. Results The simulation program had a large effect on the intervention group's clinical judgment (η2 = .143) and clinical competence (η2 = .153). There were no statistically significant differences for each outcome at baseline as compared to the final scenario for the intervention group. There was no statistical significance between the intervention and control groups in clinical judgment in the practice setting at each measurement time. Conclusion Replication of the study with a randomized controlled trial and large sample size is warranted.

Objective To systematically evaluate the prevalence of disclosed and undisclosed financial conflicts of interest (FCOI) among clinical practice guidelines (CPGs). Methods In this systematic review, we ascertained the prevalence and types of FCOI for CPGs from January 1, 1980, to March 3, 2019. The primary outcome was the prevalence of FCOI among authors of CPGs. FCOI disclosures were compared between medical subspecialties and societies producing CPGs. Results Among the 37 studies including 14,764 total guideline authors, 45% had at least one FCOI. The prevalence of FCOI per study ranged from 6% to 100%. More authors had FCOI involving general payments (39%) compared with research payments (29%). Oncology, neurology, and gastroenterology had the highest prevalence of FCOI compared with other medical specialties. Among the 8 studies that included the monetary values in US dollars of FCOI, average payments per author ranged from $578 to $242,300. Among the 10 studies that included data on undisclosed FCOI, 32% of authors had undisclosed industry payments. Conclusion There are numerous FCOI among authors of CPGs, many of which are undisclosed. Our study found a significant difference in FCOI prevalence based on types of FCOI and CPG sponsor society. Additional research is required to quantify the implications of FCOI on clinical judgment and patient care.

Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.

The diagnosis homicide by unspecified means (HUM) is used to categorize deaths occurring under suspicious or criminal circumstances, but a specific cause of death cannot be identified. In 2010, Matshes and Lew (Am J Forensic Med Pathol. 2010;31(2):174-177) presented a HUM cases series, from which they derived 5 diagnostic criteria; however, the accuracy of these criteria has not been assessed.To identify a validation cohort, Cuyahoga County Medical Examiner's Office records were searched from 2008 to 2019 for cases certified as HUM. Thirteen cases were identified; on review, all cases fulfilled criteria 1, 4, and 5. Only 1 case had a potential anatomic cause of death identified (criterion 2).However, in 3 cases, toxicologic analyses could not be conducted because of skeletonization; in 2 cases, the decedents tested positive for cocaine/benzoylecgonine but were found in proximity to other victims for whom a specific violent cause of death was determined. By strict reading of criterion 3, these cases would have been excluded from the diagnosis of HUM. Perpetrators confessed to homicide in 7 cases, including the 5 cases that failed the toxicologic criterion. The 2010 diagnostic criteria are a reasonable foundation for the determination of HUM; modification of criterion 3 would provide improved flexibility based on clinical judgment.

Background Clinical reasoning and clinical judgment have been identified as essential skills for the delivery of quality patient care. Purpose The purpose of this study was to determine the impact of clinical reasoning seminars (CRSs) on medical-surgical specialty HESI examination scores of high-risk students. Methods A retrospective correlational design was used for this study, which involved a review of medical-surgical HESI scores for 115 junior-level baccalaureate nursing students who were identified as academically high-risk and who participated in a series of CRSs. Results The participation in CRSs by high-risk students did not have a statistically significant impact on the medical-surgical HESI scores. Students who attended CRSs, however, had a higher mean medical-surgical HESI score than students who did not attend any CRSs. Conclusion Although statistical differences were not found, it appears that high-risk students may have benefitted from participation in CRSs.

The tibial pilon fracture is a complex lesion, which requires experienced clinical judgment and adequate planning to achieve good results. Treatment concepts enunciated by Ruedi and Allgower remain valid but have undergone modifications. The reconstitution of the fibular length is not always the first step to be performed. In the reconstruction of the articular surface, the prognosis is already sealed by the initial cartilage damage, and it is better to achieve stability and alignment. The stabilization of the medial column is essential, but it must be associated with the stabilization of at least one other column in complex fractures.

In evidence-based practices, narratives are the vehicle through which medical knowledge is shared and clinical judgment is grounded. This paper explores narratives as a sanctioned social practice that help a group of clinicians in a healthcare institution in New Zealand build and negotiate expertise and accountability, as they discuss clinical cases. To this end, the paper investigates narratives in six staff meetings, which were video and audio recorded. The paper presents a discursive analysis of the functions of narratives in this context to show how narratives are interactional achievements that are pivotal to clinical decision-making and to building and contesting professional stances. Finally, the paper reflects on the value of narratives as shared resources that are sometimes revisited and reframed over time and that help construct a common thread of history that becomes part of the cultural capital of the organization and positions clinicians as core members of their community.

Background: Long-term insertion of the tracheostomy tube may lead patients to have complications such as tracheal stenosis, leakage, sepsis or aspiration. Aim of the work: Our study aimed at applying standards for decannulation of the tracheostomy tube depending on the expertise from prior studies. Methods: The study included 102 patients who underwent tracheostomy during the study period. Results: Surgical tracheostomy was done in operating room in 67% of patients and in intensive care unit by percutaneous dilatational technique in 33% of patients. Decannulation was successful in 97.7% of patients and discharged from the hospital within 24-48 hours. Decannulation failed in 2.3% of patients. Conclusion: The decision to perform elective decannulation of the tracheostomy tube can be challenging. However, we have demonstrated that decannulation based on objective criteria is effective in improving clinical judgment and weaning safety, with a low failure rate. We did not encounter any mortality or significant adverse events.

As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE). The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed ex vivo and in vivo animal models. Participants’ demographics, training, and clinical experience were recorded. Trainees’ evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees’ skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed. 162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees’ endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores; p = 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice. Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.

Background Chest pain scores allow emergency physicians to identify low-risk patients for whom discharge can be safely expedited. While their utility have been extensively studied and validated in Western cohorts, data in patients of Asian heritage is lacking. This study aimed to determine the accuracy of HEART, EDACS and GRACE in risk-stratifying which emergency patients with chest pain or angina-equivalent symptoms are at risk of major adverse cardiovascular events (MACE) within 30 days (composite of all-cause mortality, acute myocardial infarction, and coronary revascularization). This single-centre prospective cohort-study enrolling 1200 patients was conducted by a large urban tertiary centre in Singapore. The chest pain scores were reported prior to disposition by research assistants blinded to the physician’s clinical assessment. Outcome adjudication was performed by an independent blinded cardiologist and emergency physician, while a second cardiologist adjudicated in the case of discrepancies. \Results Of 1200 patients enrolled, 5 withdrew consent and were excluded from analyses. 135 patients (11.3%) suffered MACE within 30 days. HEART, which ruled-out acute coronary syndrome in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled-out acute coronary syndrome in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment which ruled-out acute coronary syndrome in 73.0% of patients with 85.5% sensitivity. GRACE was weaker – ruling-out acute coronary syndrome in 79.2% of patients but with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was also superior to EDACS (69.9%) and GRACE (69.2%). Conclusions HEART more accurately identified low-risk chest pain patients in an Asian emergency department who were suitable for expedited discharge and demonstrated comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients in the emergency department.

Objective To explore whether the neutrophil-to-lymphocyte ratio (NLR) and its changes are related to tumor recurrence in grade II-IV glioma patients. Methods One hundred patients who underwent two surgeries (first for diagnosis and the second for recurrence) were retrospectively analyzed. Complete blood count was obtained preoperatively before any treatment. Basic NLR (before the first surgery) and NLR changes were calculated. Tumor recurrence was evaluated by progression-free survival (PFS) using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to determine the potential prognostic factors for PFS. Results The PFS of patients with high basic NLR (≥4) (median 9 months) was shorter than that of patients with low basic NLR (

Background Injective procedures using polynucleotides‐based products to promote dermal rejuvenation and revitalization are steadily evolving, yet no structured protocols are available that discuss and provide guidance in aesthetic treatments with highly purified polynucleotides. The goal of this document was to provide consensus‐based recommendations for the safe and effective use of Polynucleotides Highly Purified Technology™ (PN‐HPT™) devices for skin rejuvenation. Patients/Methods A team of eight experts with extensive experience in treatments for skin rejuvenation and revitalization integrated the best available evidence and clinical judgment and devised a series of practical guidance to support dermatologists, plastic surgeons, and aesthetic physician in the use of PN‐HPT™ products, alone and in combination, in aesthetic medicine. Results For most items, the expert group achieved a majority consensus. “Recommendations” (consensus >80%) were reached for the face, periocular area, décolleté and neck, hands, scalp, and stretch marks. Recommendations include details of techniques, information on dosage, volumes to be injected, and the ideal number of required treatment sessions, as well as time intervals between them for different areas of face and body. A lower agreement level of 60% was reached on but one item related to the initial treatment cycle for the face, leading to a “Consensus statement” for that area instead of a full “Recommendation.” Conclusion The expert consensus illustrates the value of natural‐origin, highly purified polynucleotides (PN‐HPT™) as biostimulatory booster strategy for skin priming and revitalization of face and body and provides a detailed guide for the use.

Background Geriatric assessment (GA) is an appropriate method for identifying frailty in older patients with cancer, but a shorter instrument may be easier to use in clinical practice. Clinical judgment is always available and requires no investments in time or resources. The purpose of this study was to assess correlations between clinical judgment for frailty of the cancer specialist, the general practitioner and patient's self-assessment, and the correlation between clinical judgment and GA. Methods This was a dual-center inception cohort study of patients with cancer aged ≥70 years starting curative or first-line palliative chemotherapy. GA included the following domains: (instrumental) activities of daily living, nutrition, mobility, cognition, mood, and polypharmacy. Clinical judgment for frailty was rated on a scale from 0 to 10 (0 = not frail, 10 = frail). Correlation was tested using Kendall's tau-b correlation coefficient. Results Of all 55 patients, 76% had ≥2 geriatric impairments. Median clinical judgment frailty score was 3 (range 1–10 for cancer specialist and patient and range 0–10 for general practitioner) and did not vary much according to the number of impaired geriatric domains (ranging from 2 for 0–1 impaired domains to 4 for ≥3 impaired domains). Correlations between mutual clinical judgment scores and between clinical judgment and GA were negligible or low. Conclusion Correlations between clinical judgment scores and between clinical judgment and GA were poor. Most patients with multiple geriatric impairments had low ‘subjective’ frailty scores. Other frailty assessments, such as frailty screening tools or GA, should be considered in addition to clinical judgment when selecting older patients for potential treatment with chemotherapy.

Introduction We aimed to report the impact of the pandemic lockdown period on the treatment and prognosis of superficial gastrointestinal neoplastic lesions. Methods A survey was completed by 11 centers from four continents regarding postponements during the early lockdown period of the pandemic, and the same period in 2019. Results In 2020, 55 % of the scheduled procedures were deferred, which was 11 times higher than in 2019; the main reasons were directly related to COVID-19. In countries that were highly affected, this proportion rose to 76 % vs. 26 % in those where there was less impact. Despite the absolute reduction, the relative distribution in 2019 vs. 2020 was similar, the only exception being duodenal lesions (affected by a 92 % reduction in mucosectomies). Although it is expected that the majority of postponements will not affect the stage (based on the results from biopsies and/or endoscopic appearance), 3 % of delayed procedures will probably require surgery. Conclusions The lockdown period caused by the SARS-CoV-2 pandemic led to a substantial reduction in the number of endoscopic resections for neoplastic lesions. Nevertheless, based on clinical judgment, the planned median delay will not worsen the prognosis of the affected patients.

Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis-associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data.

More than two decades after the introduction of cardiac resynchronization therapy (CRT) into clinical practice, respond to highly effective treatments for refractory drug heart failure (HF) approximately one-third of candidates persist to fail. This article will discuss indications for initiating a CRT, the definition of a response to a CRT, steps in response to a CRT, predictors of a CRT response, clinical judgment of patients who do not respond to CRTs, and elimination for possible reversible non-response causes. Here we have reviewed non-response CRTs in many ways. In short, multidisciplinary efforts are needed to overcome them because of the multifactorial causes of non-response (NR). So far, several factors has slowed the progress, such as limitations of NR consensus definitions and technology for therapeutic delivery. Keywords: Cardiac Resynchronization Therapy, Responder, Non-responder

Background Nurses begin forming judgments regarding patients’ clinical stability during change-of-shift handoffs. Objectives To examine the agreement between incoming and outgoing nurses’ judgments of deterioration risk following handoff and compare these judgments to commonly used early warning scores (MEWS, NEWS, ViEWS). Methods Following handoffs on three medical/surgical units, nurses completed the Patient Acuity Rating. Nurse ratings were compared with computed early warning scores based on clinical data. In follow-up interviews, nurses were invited to describe their experiences of using the rating scale. Results Sixty-two nurses carried out 444 handoffs for 158 patients. While the agreement between incoming and outgoing nurses was fair, correlations with early warning scores were low. Nurses struggled with predicting risk and used their impressions of differential risk across all the patients to whom they had been assigned to arrive at their ratings. Conclusion Nurses shared information that influenced their clinical judgments at handoff; not all of these cues may necessarily be captured in early warning scores.

Ventricular stand still is an electrophysiologic phenomenon characterized by the absence of ventricular activity or contraction. It is the result of the lack of impulse formation in ventricles (absence of idioventricular automaticity) or the failure of impulse transmission to ventricles (conduction disturbance) [1]. It is an uncommon condition that can affect a wide range of age groups with life threatening consequences. There are no set guidelines on the treatment of ventricular standstill – swift and sound clinical judgment is required. The condition should be treated as a cardiac arrest, with resolution of precipitating factors. Here we present a case of a 59-year-old man with multiple comorbidities, who presented with massive gastrointestinal hemorrhage and recurrent episodes of ventricular standstill during hospitalization, with his immediate treatment and stabilization.

La enfermedad por coronavirus 2019 o COVID-19 se transmite principalmente a través de gotas respiratorias, contacto cercano no protegido, y procedimientos generadores de aerosoles (3). Las pruebas realizadas en un laboratorio de sueño y la terapia con presión positiva como el CPAP o BPAP, pueden aumentar el riesgo de exposición de transmisión de COVID 19 al personal médico y pacientes. Las decisiones basadas en la evidencia son el estándar ideal, sin embargo, esta evidencia va apareciendo poco a poco, a un ritmo mas lento que la emergencia de salud publica que estamos viviendo; por tanto, por el momento debemos basar nuestras decisiones en la experiencia, en documentos de consenso, cuando esten disponibles, y el juicio clinico cuando no exista evidencia. Nuestro objetivo es dar unas recomendaciones, teniendo como marco de referencia las dictadas por organismos nacionales e internacionales, como la Academia Americana de Medicina del Sueño, la Academia Mexicana de Medicina del dormir, y otras publicaciones en revistas indexadas. (1,2)

Clinical assessment of the work of breathing (WOB) remains a cornerstone in respiratory support decision-making in the pediatric intensive care unit (PICU). In this study, we determined the interobserver agreement of 30 observers (PICU physicians and nurses) on WOB and multiple signs of effort of breathing in 10 spontaneously breathing children admitted to the PICU. By reliability analysis, the agreement on overall WOB was poor to moderate, and only three separate signs of effort of breathing (breathing rate, stridor, and grunting) showed moderate-to-good interobserver reliability. We conclude that the interobserver agreement on the clinical WOB judgment among PICU physicians and nurses is low.

Purpose of review The aim of this article is to provide practical recommendations on safe initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors to in-patients as well as management of those who are already on SGLT2 inhibitors. Recent findings Robust data from stable outpatient cohorts indicate that the SGLT2 inhibitors are associated with clinically meaningful reductions in major adverse cardiovascular events, lower rates of hospitalization for heart failure, and a reduction in major kidney outcomes There is however a lack of information on how to initiate and manage SGLT2 inhibitors in an acute in-patient setting. Summary SGLT2 inhibitors may be cautiously appropriate for in-patients if all the criteria for safe use are met but good clinical judgment must prevail. Temporary withholding of SGLT2 inhibitors is appropriate in hospitalized patients during a period of stress and/or insulinopenia.

Background Nurse practitioner (NP) autonomy is often misunderstood and misconstrued. These misconceptions cause a confusing interplay of words that impedes advocating for policy change and ultimately hinders the profession. Objective To develop a clear definition of NP autonomy to describe the professional role. Data sources Walker and Avant's method of concept analysis was used to undertake a concept analysis of NP autonomy. The terms used to search for possible uses and definitions of NP autonomy in electronic databases included NP, autonomy, and concept analysis. In addition, the websites for nursing organizations, Google, Google Scholar, and the Merriam-Webster dictionary were searched and included in this analysis. This search yielded 29 articles, consisting of literature reviews, meta-synthesis, position papers, and qualitative and quantitative studies. Conclusions Nurse practitioner autonomy should be defined as the NP's use of their experience, clinical judgment, and responsibility to practice without restriction in professional collaboration with other health care professionals. Autonomy allows NPs to practice to the maximum extent of their advanced education, participate in productive and voluntarily collaborations, and continue to positively influence health care discrepancies throughout the United States. Implications for practice This concept analysis provides a clear definition of NP autonomy. In addition, it explains the difference between the concepts of NP autonomy and full practice authority. Clear definitions of the concepts of NP autonomy and full practice authority will be beneficial in advocating and advancing policy on behalf of NPs.

Background Sex estimation using the subpubic angle of the pelvis is highly accurate for identification of unknown skeletonized remains. This study compared two methods for measuring the subpubic angle from reconstructed three-dimensional (3D) pelvic models. The aims were to quantify the differences in the subpubic angle measurement by Checkpoint (Method 1) and MeshLab + OnScreenProtractor (Method 2), to determine the 95% limits of agreement and to identify any measurement bias. Multislice computed tomography (MSCT) scans of 85 individuals were used in this study. The MSCT scans were performed on a Siemens SOMATOM Sensation 64 scanner (Siemens Germany Ltd.). Segmentation of the MSCT scans was performed using 3D Slicer to reconstruct 3D pelvic models. Subpubic angle was measured on Checkpoint using four landmarks (Method 1), and with OnScreenProtractor on MeshLab (Method 2). Results The intraclass correlation coefficient (ICC) showed a high correlation between repeated measurements in both methods. Subpubic angle measurements by Method 1 and Method 2 were significantly different (p < 0.05). Method 2 (M = 82.2°, SD = 13.5°), consistently showed a larger subpubic angle measurement than Method 1 (M = 77.3°, SD = 12.3°) (consistent bias). More than 95% of the differences (82/85) between Checkpoint and MeshLab fell within the 95% limits of agreement (− 1.4° and 11.4°). Conclusion Checkpoint and MeshLab displayed significantly different subpubic angle measurement on a 3D pelvic model, but within the 95% limits of agreement. The MeshLab tended to give a larger measurement (5°), across the magnitude of the subpubic angle. The decision to use the two methods interchangeably depended on the clinical judgment of the observer.

Introduction: In the emergency department, the decisions on admission or discharge are based on clinical symptoms and physical examinations. The aim of this study is to compare the assessment of emergency physician clinical judgment accuracy with the actual amount of peak expiratory flow rate (PEFR). Method: The present research was a cross-sectional study. In this study, 138 patients with asthma of the age of 18 to 55 years were enrolled. From admission to discharge, clinical signs and symptoms were investigated and recorded by emergency physicians and the severity of asthma was determined (mild, moderate, severe). In both stages (admission and discharge), the PEFR was measured by researcher and was compared with the severity of asthma, which are determined based on clinical symptoms and physical examination. Results: 37.7% of patients were male and the rest were females, and the mean age of participants was 49.84 years. The number of mild, moderate and severe asthma cases was 14, 36 and 88, respectively in peak flow meter. The number of mild, moderate and severe asthma cases was 37, 32 and 69, respectively in clinical judgment. In assessment of emergency physician clinical judgment accuracy in severity of asthma in comparison with peak flowmetry, the result was the kappa value of 0.231 (P

Aim To assess the ability of the patient main problem to predict acuity in adults admitted to hospital wards and step‐down units. Background Acuity refers to the categorization of patients based on their required nursing intensity. The relationship between acuity and nurses' clinical judgment on the patient problems, including their prioritization, is an underexplored issue. Method Cross‐sectional, multi‐centre study in a sample of 200,000 adults. Multivariate analysis of main problems potentially associated with acuity levels higher than acute was performed. Distribution of patients and outcome differences among acuity clusters were evaluated. Results The main problems identified are strongly associated with patient acuity. The model exhibits remarkable ability to predict acuity (AUC, 0.814; 95% CI, 0.81–0.816). Most patients (64.8%) match higher than acute categories. Significant differences in terms of mortality, hospital readmission and other outcomes are observed (p

Background: The prevention of pressure injuries/ulcers (PI/PUs) in patients at the end of life is achievable, albeit challenging. Objective diagnostic tools, such as sub-epidermal moisture (SEM) scanning, support healthcare practitioners' clinical judgment in preventing PI/PUs. Aim: A pragmatic study was conducted to assess the feasibility of preventing PI/PUs using SEM technology as an adjunct to routine care in a 22-bed inpatient hospice. Methods: Daily SEM scanning was introduced to support the device-trained practitioners' clinical judgment in detecting developing, non-visible PI/PUs. Preventive interventions were initiated by clinical judgment informed by Waterlow scores, visible, tactile skin and tissue assessments and scanner readings. Results: Prior to the study, the incidence of PI/PUs was 9%. The 6 month study period reported a 4.8% PI/PU incidence, 7/146 consenting patients developed a PI/PU, resulting in a 47% reduction in incidence rates. Conclusion: Preventing the development of PI/PUs is possible with clinical judgment aided by SEM data.

Background Prognostic assessments of the mortality of critically ill patients are frequently performed in daily clinical practice and provide prognostic guidance in treatment decisions. In contrast to several sophisticated tools, prognostic estimations made by healthcare providers are always available and accessible, are performed daily, and might have an additive value to guide clinical decision-making. The aim of this study was to evaluate the accuracy of students’, nurses’, and physicians’ estimations and the association of their combined estimations with in-hospital mortality and 6-month follow-up. Methods The Simple Observational Critical Care Studies is a prospective observational single-center study in a tertiary teaching hospital in the Netherlands. All patients acutely admitted to the intensive care unit were included. Within 3 h of admission to the intensive care unit, a medical or nursing student, a nurse, and a physician independently predicted in-hospital and 6-month mortality. Logistic regression was used to assess the associations between predictions and the actual outcome; the area under the receiver operating characteristics (AUROC) was calculated to estimate the discriminative accuracy of the students, nurses, and physicians. Results In 827 out of 1,010 patients, in-hospital mortality rates were predicted to be 11%, 15%, and 17% by medical students, nurses, and physicians, respectively. The estimations of students, nurses, and physicians were all associated with in-hospital mortality (OR 5.8, 95% CI [3.7, 9.2], OR 4.7, 95% CI [3.0, 7.3], and OR 7.7 95% CI [4.7, 12.8], respectively). Discriminative accuracy was moderate for all students, nurses, and physicians (between 0.58 and 0.68). When more estimations were of non-survival, the odds of non-survival increased (OR 2.4 95% CI [1.9, 3.1]) per additional estimate, AUROC 0.70 (0.65, 0.76). For 6-month mortality predictions, similar results were observed. Conclusions Based on the initial examination, students, nurses, and physicians can only moderately predict in-hospital and 6-month mortality in critically ill patients. Combined estimations led to more accurate predictions and may serve as an example of the benefit of multidisciplinary clinical care and future research efforts.

This article highlights the quagmire of the surgeon who encounters a small bowel obstruction in the absence of previous abdominopelvic surgery. Historic literature implies urgent surgical intervention is required; however, there is no current standard of care to guide management. Key principles of general surgery apply, and definitive management is based on the provider's clinical judgment after synthesizing key clinical history and additional diagnostic imaging studies.

Therapeutic Drug Monitoring (TDM) is the clinical pharma cy practice of measuring plasma level of drugs. This service is required to optimize the drug therapy in individual patient and should be considered an adjunct to physician’s clinical judgment in assessing the course and the effectiveness of treatment, especially in critically ill patients. Indonesia has not been developed this service. Therefore, this article discus the roles and function of a best practice TDM service and how can this service be implemented in Indonesia.

In view of the increasing complexity of both cardiovascular implantable electronic devices (CIEDs) and patients in the current era, practice guidelines, by necessity, have become increasingly specific. This document is an expert consensus statement that has been developed to update and further delineate indications and management of CIEDs in pediatric patients, defined as ≤21 years of age, and is intended to focus primarily on the indications for CIEDs in the setting of specific disease categories. The document also highlights variations between previously published adult and pediatric CIED recommendations and provides rationale for underlying important differences. The document addresses some of the deterrents to CIED access in low- and middle-income countries and strategies to circumvent them. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by class of recommendation and level of evidence. Several questions addressed in this document either do not lend themselves to clinical trials or are rare disease entities, and in these instances recommendations are based on consenus expert opinion. Furthermore, specific recommendations, even when supported by substantial data, do not replace the need for clinical judgment and patient-specific decision-making. The recommendations were opened for public comment to Pediatric and Congenital Electrophysiology Society (PACES) members and underwent external review by the scientific and clinical document committee of the Heart Rhythm Society (HRS), the science advisory and coordinating committee of the American Heart Association (AHA), the American College of Cardiology, (ACC) and the Association for European Paediatric and Congenital Cardiology (AEPC). The document received endorsement by all the collaborators and the Asia Pacific Heart Rhythm Society (APHRS), the Indian Heart Rhythm Society (IHRS), and the Latin American Heart Rhythm Society (LAHRS). This document is expected to provide support for clinicians and patients to allow for appropriate CIED use, appropriate CIED management, and appropriate follow-up in pediatric patients.

Antimicrobial drugs play an important, often central, role in the therapeutic management of mature horses and foals with a variety of illnesses, including those requiring critical care. Antimicrobial use must be based on rational principles involving thorough patient evaluation and sound clinical judgment that indicate a high likelihood that the patient has a bacterial infection and that antimicrobials are indicated to promote recovery. The aim of antimicrobial treatment is to inflict an insult on infecting bacteria sufficient to kill the organism or render it susceptible to inactivation by natural host defenses or the local microenvironment without adversely affecting the patient.

IntroductionThis study aimed to analyze the correlation between the serum insulin-like growth factor 1 (IGF-1) and body weight and provide some bases for the clinical judgment of the influencing factors on children's height.Material and methodsA total of 333 children with a height of less than the 10th percentile were enrolled in this study. Among these children, 212 were male and 121 were female. The age of these children ranged within 5-14-years-old. Serum IGF-1 level was detected and the Z-scores (SDS) of the children’s height, weight, and body mass index (BMI) were measured. The correlation among the factors was analyzed using Pearson’s correlation analysis.ResultsAge, body weight, body weight SDS, BMI and BMI SDS were all correlated with the serum IGF-1 level (PConclusionsThe correlation between body weight and the serum IGF-1 level is not high and it can provide some basis for the clinical judgment of the influencing factors on children's height. However, it is not the main factor affecting height.

A question that routinely arises in medical device clinical studies is the homogeneity across demographic subgroups, geographical regions, or investigational sites of the enrolled patients in terms of treatment effects or outcome variables. The main objective of this paper is to discuss statistical concepts and methods for the assessment of such homogeneity and to provide the practitioner a statistical framework and points to consider in conducting homogeneity assessment. Demographic subgroups, geographical regions, and investigational sites are discussed separately as each has its unique issues. Specific considerations are also given to randomized controlled trials, non-randomized comparative studies, and single-arm studies. We point out that judicious use of statistical methods, in conjunction with sound clinical judgment, is essential in handling the issue of homogeneity of treatment effect in medical device clinical studies.

The design of digital information management systems for healthcare presents developers with several formidable engineering challenges. These systems must manage huge amounts of data and support communications across disparate platforms and divisions within a healthcare organization. They must ensure that data is kept private, secure, and available to the right people at the right time. However, as shown in other complex systems (e.g., nuclear power), simply making data available may be insufficient. The goals in designing digital healthcare as a ‘cognitive system’ are to present patient information in more meaningful ways, to help healthcare professionals become more productive, and to support healthcare professionals with clinical decision making. This paper describes how principles of cognitive systems engineering (CSE) and user experience (UX) design were applied to Cardiac Consultant, an interactive cardiovascular risk calculator, with those goals in mind.

Objectives This study was conducted to assess the applicability of the Appropriateness Evaluation Protocol (AEP) for public hospitals in Korea. Methods In May 2016, 1500 admission claims were collected from Korean public district hospitals using stratified random sampling. Of these claims, 560 admissions to 37 hospitals were retrieved for analysis. Medical records administrators determined the appropriateness of admission using the criteria detailed in the AEP, and a physician separately assessed the appropriateness of admission based on her clinical judgment. To examine the applicability of the AEP, the concordance of the decisions made between a pair of AEP reviewers and between an AEP reviewer and a physician reviewer was compared. Results The results showed an almost perfect inter-rater agreement between the AEP reviewers and a moderate agreement between the AEP reviewers and the physician. The sensitivity and specificity of the AEP were calculated as 0.86 and 0.56, respectively. Conclusions Our findings suggest that the AEP could potentially be applied to Korean public hospitals as a reliable and valid instrument for assessing the appropriateness of admissions.

Background Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited. Aims The aim of this study was to explore nurses’ assessment of pain in hospitalized preverbal children based on self-selected clinical examples. Design Qualitative, descriptive design. Settings Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use. Participants/Subjects Nurses (N = 22) with ≥1 year experience caring for preverbal children. Methods Individual, semistructured interviews. Data were analyzed using inductive thematic analysis. Results Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment. Conclusions Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

The aim of the present study was to investigate the use and attitudes toward standardized assessment tools among clinicians in a public mental health service in Norway. A total of 606 clinicians provided feedback on their use and attitudes regarding psychometric qualities of such tools, their practicality, and their benefit over clinical judgment alone using the Attitudes toward Standardized Assessment (ASA) Scales. Clinicians working in the adult mental health field scored significantly higher on use of diagnostic interviews, pre-post evaluations, and ongoing evaluations, whereas clinicians working in the child/adolescent mental health field scored significantly higher on use of screening instruments and held more positive attitudes towards using standardized assessment tools. Attitudes toward standardized assessment tools predicted use of such tools, and results were found to be similar to a study on US clinicians. Whereas the US study only found attitudes regarding the practicality of using such instrument as an independent predictor of assessment use, the current study found that attitudes regarding psychometric qualities of such tools, their practicality, and their benefit over clinical judgment alone were independent predictors of use.

Since its diagnostic inception, autism has garnered stigma and fear, often to the exclusion of action. Early detection and treatment of autism spectrum disorders have become crucial priorities of the National Institutes of Health. The primary care provider is the point of entry to the health care system for infants/children showing risk factors for autism spectrum disorders and/or symptoms of the disorder. Despite the existence of low-cost, well-tested developmental screening tools, many primary care providers rely solely on clinical judgment to ascertain developmental status. Current best screening practices were determined by a review of the literature. Key recommendations are highlighted.

Objective The objective of this study was to compare the accuracy of clinical judgment in predicting seizure outcome after resective epilepsy surgery relative to two recently published statistical tools [the Epilepsy Surgery Nomogram (ESN) and the modified Seizure-Freedom score (m-SFS)]. Methods Details of presurgical evaluations of 20 patients who underwent epilepsy surgery were presented to 20 epilepsy experts. The final surgical treatment was also disclosed. The clinicians were asked to predict the likelihood of a good outcome (Engel 1) at 2 and 5 years in each case. The ESN and the m-SFS predictions were calculated with the data provided to the clinicians. The discriminative ability of clinical judgment, ESN, and m-SFS was assessed by calculating a concordance index (C-index). Expert opinion, the m-SFS and the ESN performances were compared using a Receiver Operating Characteristic (ROC) curve analysis. Results The mean age at surgery was 29 years (standard deviation [SD] = 14); 40% were male; 70% were right-handed, and thirteen (65%) had an Engel outcome 1 at 2 and 5 years. The mean C-index for the mean physician's prediction was 0.478 with a variance of 0.012. The ESN had an area under the curve (AUC) of 0.528 and 0.533 for the 2-year and 5-year predictions in comparison with the clinicians' predictions that was 0.476, and 0.466, respectively. For the m-SFS, the AUC at 2 years and 5 years was 0.539 and 0.539, respectively. No statistical difference was noted between the ESN and the clinicians or between m-SFS and the ESN, but there is a moderate statistical difference favoring the m-SFS to the clinicians (p 0.0960 and 0.0514, for 2 and 5 years). Significance Clinical judgment was not superior to the ESN nor to the m-SFS. Together with the interphysician's prediction variability, our findings reinforce the need for better tools to predict postoperative outcomes.

Objectives To examine the effect of maternal reverse-sequence (RS) syphilis screening on management of infants at risk for congenital syphilis (CS) using a standardized approach. Study design A retrospective study from 2011 to 2014 at an academic medical center using RS testing, involving chemiluminescent immunoassay (CIA), rapid plasma reagin (RPR), and fluorescent treponemal antibody-absorption (FTA-ABS) assays for syphilis. Clinical management and outcomes of infants born to mothers with discordant (CIA+/RPR-/FTA+) serology were compared with national or internal guidelines. Results Sixty-three infants were classified as discordant (n = 21), presumed false positive (CIA+/RPR-/FTA-; n = 16), or true positive (CIA+/RPR+; n = 26) based on maternal serology. Only 24% of cases in the discordant group underwent recommended full evaluation. None of the evaluated infants in the discordant group (n = 8) were diagnosed with CS. Conclusions Management of infants with discordant maternal RS serology remained reliant on clinical judgment. In our high-risk population, RS testing did not identify additional cases of CS.

The advent of T-cell-mediated immunotherapy has led to a new era in the treatment of relapsed, refractory B-cell lymphomas and leukemias. Chimeric antigen receptor T-cell and engineered T-cell receptor therapies have demonstrated impressive efficacy in treating refractory disease. The principal toxicities of these therapies include cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS), but others exist as well. Cytokine release syndrome and ICANS are typically acute events occurring within 30 days of therapy, but other on-target/off-tissue toxicities may persist for years. There is no currently accepted single approach to managing all aspects of cytokine release syndrome and ICANS. However, there are clear trends in many areas and a clear need for further consensus surrounding others. This article will discuss T-cell-mediated immunotherapy complications and their suggested management. It is not intended to be comprehensive or applicable to every patient, so practitioners should exercise sound clinical judgment. Rather, this may serve as a starting point for further management discussions in the community.