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AIM: Inappropriate anticoagulant use increases the risk of bleeding and thrombotic events. We implemented clinical decision rules to promote judicious medication use, as part of the 'Check of Medication Appropriateness' (CMA). The CMA concerns a pharmacist-led review service, targeting potentially inappropriate prescriptions (PIPs). In this analysis, we aimed to evaluate the impact of the CMA on anticoagulant prescribing. METHODS: The number of anticoagulant-related PIPs was evaluated before and after implementation of the intervention in a quasi-experimental interrupted time series analysis. The pre-implementation cohort received usual care. The anticoagulant-focused CMA, comprising 13 clinical rules pertaining to anticoagulation therapies, was implemented in the post-implementation cohort. Segmented regression analysis was used to assess the impact of the intervention on the number of residual PIPs. A residual PIP was defined as a PIP which persisted up to 48h after the CMA intervention. Total number of recommendations and acceptance rate were documented for the 2-year post-implementation period. RESULTS: Pre-implementation, we observed 501 PIPs in 466 inpatients on 36 days, with a median proportion of 78.5% (range: 46.2%-100%) residual PIPs per day. Post-implementation, 538 PIPs were detected in 485 patients over the same number of days. The CMA intervention reduced the median proportion to 18.2% (range: 0-100%) per day. The effect coincided with an immediate relative reduction of 70% (95%CI 0.19-0.46) in anticoagulant-related residual PIPs. Post-implementation, 2778 recommendations were provided and 75.1% were accepted. CONCLUSION: Our CMA approach significantly reduced anticoagulant-related PIPs. Implementing a pharmacist-led intervention, based on clinical rules, may support safer prescribing of anticoagulants. ispartof: British Journal Of Clinical Pharmacology vol:88 issue:6 pages:2959-2968 ispartof: location:England status: accepted

Objectives Inappropriate prescribing of antimicrobials in hospitals contributes to the emergence of resistance and adverse drug events. To support antimicrobial stewardship (AMS), clinical decision rules focusing on antimicrobial therapy were implemented in the ‘Check of Medication Appropriateness’ (CMA). The CMA is a hospital-wide pharmacist-led medication review service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs). We aimed to investigate the impact of the CMA on antimicrobial prescribing. Methods An interrupted time series study was performed at the University Hospitals Leuven. The pre-implementation cohort was exposed to standard-of-care AMS. Afterwards, an AMS-focused CMA comprising 41 specific clinical rules, targeting six AMS objectives, was implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of AMS-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the 2 year post-implementation period. Results Pre-implementation, a median proportion of 75% (range: 33%–100%) residual PIPs per day was observed. After the CMA intervention, the proportion was reduced to 8% (range: 0%–33%) per day. Use of clinical rules resulted in an immediate relative reduction of 86.70% (P Conclusions We proved that the CMA approach reduced the number of AMS-related residual PIPs in a highly significant and sustained manner, with the potential to further expand the service to other AMS objectives.

BACKGROUND Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing. METHODS A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period. RESULTS At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p

Telemedicine gained interest in liver transplant patients but focused until now on the early post-operative period. This prospective cohort study assessed feasibility, safety, and clinical beneficial effects of a telemedicine based remote monitoring program (TRMP) for the chronic follow-up of adult liver transplant recipients. Between November 2017 and August 2019, a total of 87 of the 115 selected patients (76%) started the TRMP. Over the 2 years study period, none of the patients switched to standard follow-up: 39/87 (45%) continued to do this autonomously and 48/87 (55%) stopped to report their data personally but communicated their lab values to the nurse. The other 28/115 (11%) patients who did not accept the TRMP continued the standard follow-up. There was no difference in educational level between the three groups. Remote monitoring did not result in an increase in liver graft rejection and need of hospitalization. TRMP was associated with a higher number of tacrolimus level determinations and tacrolimus blood level concentrations could be kept lower. In conclusion, our results show that in patients with a stable clinical condition there is a high willingness to participate in TRMP and that this approach is safe. Remote monitoring allowed a stringent follow-up of tacrolimus levels. ispartof: CLINICAL TRANSPLANTATION vol:36 issue:1 ispartof: location:Denmark status: published

This chapter introduces a theory that combines both schools by preserving their strong and overcoming their weak points which allows for formulating practical guidelines for implementing International Humanitarian Law (IHL) in military operations below the threshold of attack. In international armed conflict, captured combatants are granted a prisoner of war status, while in non-international armed conflict fighters might be criminally prosecuted for their engagements. New technologies, especially the development of the cyber domain, have created a number of possibilities to fight a war with lethal but even more with non-lethal means methods. To achieve these goals, the main focus has been on the reduction of the horrors of war. IHL defines a balance between those primary principles in more pragmatic terms, it sets the rules to win a war, while simultaneously reducing the horrors of war. The problem with both schools is that the permissive school is generally seen as too permissive while the restrictive school is considered restrictive.

Objectives: Telemonitoring can be implemented to enhance disease monitoring and ultimately reduce the number of outpatient visits and associated costs. We developed an in house IBD mobile app and established a proof of concept study to demonstrate the effectiveness and accuracy of the telemonitoring tool for monitoring of disease activity.Methods: An IBD mobile app was designed through close collaboration between the Information Technology and Gastroenterology department of University Hospitals of Leuven. The study was proposed to all patients in remission under stable biological therapy visiting the outpatient clinic. During one-year follow-up, patients completed weekly and monthly questionnaires on their mobile device or on a website. Entered data were directly sent to the electronic medical record. Predefined red flags or alerts, generated by the answers to the questionnaires, were monitored daily.Results: The pilot study in 45 patients demonstrated accurate monitoring of disease activity with fast intervention during flares. During the 12-months follow-up period, an alert for disease activity was generated for 9 different patients out of 1296 completions of the questionnaire. Symptoms resolved spontaneously in 8 patients. One patient reported consecutive PRO-2 increase, endoscopy confirmed an IBD flare and therapy was switched. For the remaining 36 included patients, no alerts indicating disease activity increase were reported. Median compliance to all weekly and monthly questionnaires during 1 year was 52% (IQR: 24-91).Conclusions: We developed the mynexuzhealth IBD app with full integration in the electronic medical record. The app enabled continuous remote monitoring and showed accurate detection of flares. ispartof: SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY vol:55 issue:3 pages:287-293 ispartof: location:England status: published

Sovereignty is a complex notion of international law, and not less disputed in the current digital era. Some States question whether sovereignty is a ‘mere’ principle of international law in the virtual cyberspace or a binding rule. This article argues that the sovereignty of States is a primary rule of law in cyberspace, though mainly based on a violation of the political independence, rather than on the territorial integrity. In the 1960s abduction of Eichmann both territorial integrity and political independence - related to inherently governmental functions - were violated. In a fictitious remote cyber deletion of a ‘virtual Eichmann’ it is difficult to substantiate how territorial integrity in cyberspace is being violated when no physical or functional damage occurs. However, the inherent governmental functions of the State can and will be violated when a remote cyber operation is executed aimed at State functions such as taxation, law enforcement or elections, not least since these functions are less territorial in nature. Clarity regarding the exact threshold at which the inherent political functions are violated will require further State practice, but the mere question ‘when’ the breach happens illustrates the existence of a primary rule of law.

Contains fulltext : 220114.pdf (Publisher’s version ) (Closed access) BACKGROUND: With the outbreak of SARS-CoV-2, rapid diagnostics are paramount to contain the current pandemic. The routinely used realtime RT-PCR is sensitive, specific and able to process large batches of samples. However, turnaround time is long and in cases where fast obtained results are critical, molecular point of care tests (POCT) can be an alternative. Here we report on a multicenter evaluation of the Cepheid Xpert Xpress SARS-CoV-2 point-of-care test. STUDY DESIGN: The Xpert Xpress SARS-CoV-2 assay was evaluated against the routine in-house real-time RT-PCR assays in three medical microbiology laboratories in The Netherlands. A sensitivity and specificity panel was tested consisting of a dilution series of SARS-CoV-2 and ten samples containing SARS-CoV-2 and a range of other seasonal respiratory viruses. Additionally, 58 samples of patients positive for SARS-CoV-2 with different viral loads and 30 tested negative samples in all three Dutch laboratories using an in-house RT-PCR, were evaluated using Cepheids Xpert Xpress SARS-CoV-2 cartridges. RESULTS: Xpert Xpress SARS-CoV-2 point of care test showed equal performance compared to routine in-house testing with a limit of detection (LOD) of 8.26 copies/mL. Other seasonal respiratory viruses were not detected. In clinical samples Xpert Xpress SARS-CoV-2 reaches an agreement of 100 % compared to all in-house RT-PCRs CONCLUSION: Cepheids GeneXpert Xpert Xpress SARS-CoV-2 is a valuable addition for laboratories in situations where rapid and accurate diagnostics are of the essence.

Aims QTc prolongation is a complex problem linked with multiple risk factors. The RISQ-PATH score was previously developed to identify high-risk patients for QTc prolongation. The aim of this study was to optimize and validate this risk score in a large patient cohort, and to propose an algorithm to generate smart QT signals in the electronic medical record. Methods A retrospective study was performed in the Nexus hospital network (n = 17) in Belgium. All electrocardiograms performed in 2015 in both ambulatory and hospitalized patients were collected together with risk factors for QTc prolongation (training database). Multiple logistic regression was performed to obtain the optimal prediction (RISQ-PATH) model. The model was tested in a validation database (electrocardiograms between January and April 2016). Results In total, 60 208 patients (52.8% males, mean age 63 ± 18 years) were included; 3543 patients (5.9%) had a QTc ≥ 450(♂)/470(♀) ms and 453 (0.8%) a QTc ≥ 500 ms. The optimized RISQ-PATH model has an area under the ROC-curve of 0.772 [95% CI 0.763-0.780] to predict QTc ≥ 450(♂)/470(♀)ms. A predicted probability of ≥0.035 was set as cutoff for a high risk of QTc prolongation. This cutoff resulted in a sensitivity of 87.4% [95% CI 86.2-88.5] and a specificity of 46.2% [95% CI 45.8-46.6]. These results could be confirmed for QTc ≥ 500 ms and in the validation database (n = 28 400). Conclusions The RISQ-PATH model, with a cutoff probability of 0.035, predicted a prolonged QTc interval ≥ 450/470 ms or ≥500 ms with a sensitivity of ±87% and a specificity of ±45%. This RISQ-PATH model can be used in clinical decision support systems to create smart QT alerts.

Background To improve medication surveillance and provide pharmacotherapeutic support in University Hospitals Leuven, a back-office clinical service, called “Check of Medication Appropriateness” (CMA), was developed, consisting of clinical rule based screening for medication inappropriateness. The aim of this study is twofold: 1) describing the development of CMA and 2) evaluating the preliminary results, more specifically the number of clinical rule alerts, number of actions on the alerts and acceptance rate by physicians. Methods CMA focuses on patients at risk for potentially inappropriate medication and involves the daily checking by a pharmacist of high-risk prescriptions generated by advanced clinical rules integrating patient specific characteristics with details on medication. Pharmacists’ actions are performed by adding an electronic note in the patients’ medical record or by contacting the physician by phone. A retrospective observational study was performed to evaluate the primary outcomes during an 18-month study period. Results 39,481 clinical rule alerts were checked by pharmacists for which 2568 (7%) electronic notes were sent and 637 (1.6%) phone calls were performed. 37,782 (96%) alerts were checked within four pharmacotherapeutic categories: drug use in renal insufficiency (25%), QTc interval prolonging drugs (11%), drugs with a restricted indication or dosing (14%) and overruled very severe drug-drug interactions (50%). The emergency department was a frequently involved ward and anticoagulants are the drug class for which actions are most frequently carried out. From the 458 actions performed for the four abovementioned categories, 69% were accepted by physicians. Conclusions These results demonstrate the added value of CMA to support medication surveillance in synergy with already integrated basic clinical decision support and bedside clinical pharmacy. Otherwise, the study also highlighted a number of limitations, allowing improvement of the service. Electronic supplementary material The online version of this article (10.1186/s12911-019-0748-5) contains supplementary material, which is available to authorized users.

To construct an efficient dye-sensitized photo-electrochemical tandem cell for hydrogen production, it is crucial to understand the working principles of both the photoanode and the photocathode. Herein, the anchoring of a proton-reduction catalyst and an organic dye molecule on metal oxides is studied for the preparation of a photocathode. On TiO2, the Ni catalyst behaves as a good electrocatalyst (-250Acm(-2)) in acidic water (pH2). The Ni catalyst and the organic dye were co-immobilized on NiO to form a solely Ni-based photocathode. The electron-transfer steps were investigated by using various techniques (IR, UV/Vis, and fluorescence spectroscopy, and (photo)electrochemistry). Despite the observed successful single-electron-transfer steps between all of the components, photocatalysis did not yield any hydrogen gas. Possible bottlenecks that prevent photocatalytic proton reduction are poor electron transfer because of aggregation, charge recombination from the catalyst to the NiO, or instability of the catalyst after the first reduction.

The electronic coupling between a robust red algal photosystem I (PSI) associated with its light harvesting antenna (LHCI) and nanocrystalline n-​type semiconductors, TiO2 and hematite (α-​Fe2O3) is utilized for fabrication of the biohybrid dye-​sensitized solar cells (DSSC)​. PSI-​LHCI is immobilized as a structured multilayer over both semiconductors organized as highly ordered nanocrystalline arrays, as evidenced by FE-​SEM and XRD spectroscopy. Of all the biohybrid DSSCs examined, α-​Fe2O3/PSI-​LHCI biophotoanode operates at a highest quantum efficiency and generates the largest open circuit photo-​current compared to the tandem system based on TiO2/PSI-​LHCI material. This is accomplished by immobilization of the PSI-​LHCI complex with its reducing side towards the hematite surface and nanostructuring of the PSI-​LHCI multilayer in which the subsequent layers of this complex are organized in the head-​to-​tail orientation. The biohybrid PSI-​LHCI-​DSSC is capable of sustained photoelectrochemical H2 production upon illumination with visible light above 590 nm. Although the solar conversion efficiency of the PSI-​LHCI​/hematite DSSC is currently below a practical use, the system provides a blueprint for a genuinely green solar cell that can be used for molecular hydrogen production at a rate of 744 μmoles H2 mg Chl-​1 h-​1, placing it amongst the best performing biohybrid solar-​to-​fuel nanodevices.

Radiological Picture Archiving and Communication Systems (PACS) have only relatively recently become abundant. Many hospitals have made the transition to PACS about a decade ago. During that decade requirements and available technology have changed considerably. In this paper we look at factors that influence the design of tomorrow's systems, especially those in larger multidisciplinary hospitals. We discuss their impact on PACS architecture (a technological perspective) as well as their impact on radiology (a management perspective). We emphasize that many of these influencing factors originate outside radiology and that radiology has little impact on these factors. That makes it the more important for managers in radiology to be aware of architectural aspects and it may change cooperation of radiology with, among others, the hospital's central IT department.

We claim that integration of new and even experimental methods for image processing and analysis into a routine PACS is not only needed to enhance the functionality of that PACS, but also to foster introduction of those image processing methods into clinical routine. From that latter perspective it must be possible to incorporate such methods without requiring specific developments from the side of the PACS provider. In this paper we discuss some of the possibilities and difficulties. We illustrate those using initial examples of integration of image processing, by a university hospital, into a commercial PACS in routine hospital-wide operation. © 2005. Bellon E., Feron M., Neyens P., Peters K., Sweertvaegher M., Maes F., Suetens P., Van den Bosch B., ''Incorporating novel image processing methods in a hospital-wide PACS'', International congress series 19th international congress and exhibition on computer assisted radiology and surgery - CARS 2005, vol. 1281, pp. 1016-1021, June 22-25, 2005, Berlin, Germany. ispartof: pages:1016-1021 ispartof: International congress series vol:1281 pages:1016-1021 ispartof: International congress and exhibition on computer assisted radiology and surgery - CARS 2005 location:Berlin, Germany date:22 Jun - 25 Jun 2005 status: published

In the PACS that is now being installed for the University Hospitals Leuven, there is a strong emphasis on integration into the overall hospital-wide information system and on supporting interdepartmental workflow. In this paper, we focus on operations within the Radiology Department. We (1) motivate our emphasis on integration, (2) briefly describe our approach to integrating a commercial PACS, (3) situate some of the challenges we were faced with so far, and (4) report on initial experiences. We discuss integration into the overall workflow from the perspective of a changing emphasis in PACS.

We claim that to deploy PACS in large-scale clinical routine, image access and viewing must be tightly integrated within the overall user interface of the multimedia clinical workstation. First, we motivate the need for integration. Then, we propose minimal requirements for an image viewer to be integrated in a clinical workstation. Finally, we report on initial experience with integration of a commercial viewer, in developments that are part of the clinical PACS project at the University Hospitals Leuven, with emphasis on technology for integration. We discuss the aspect of integration within the broader context of PACS, and point to a potential risk for the Radiological PACS community to ignore emerging trends in building large information systems.

The dynamics of iron tetracarbonyl olefin complexes has been investigated using two-dimensional infrared (2D-IR) spectroscopy. Cross peaks between all CO-stretching bands show that the CO-stretch modes are coupled, and from the cross-peak anisotropies we can confirm previous assignments of the absorption bands. From the pump-probe delay dependence of the diagonal peaks in the 2D-IR spectrum we obtain a correlation time of [similar]3 ps for the spectral fluctuations of the CO-stretch modes. We observe a multi-exponential pump-probe delay dependence of the cross-peak intensities, with rate constants ranging from 0.1 ps−1 to 0.6 ps−1. To determine whether this delay dependence originates from fluxionality of the complex or from intramolecular vibrational relaxation (IVR), we modulate the free-energy barrier of fluxional rearrangement by varying the pi-backbonding capacities of the olefin ligand in two iron tetracarbonyl olefin complexes: Fe(CO)4(cinnamic acid) and Fe(CO)4(dimethyl fumarate). Since the pi-backbonding strongly influences the rate of fluxionality, comparing the dynamics in the two complexes allows us to determine to what extent the observed dynamics is caused by fluxionality. We conclude that on the time scale of our experiments (up to 100 ps) the cross-peak dynamics in the iron complexes is determined by intramolecular vibrational energy relaxation. Hence, in contrast to previously investigated irontricarbonyl and ironpentacarbonyl complexes, iron tetracarbonyl olefin complexes exhibit no fluxionality on the picosecond time scale.

Who needs the nobles? Ideally, devices to harvest solar energy into fuels would, in addition to having very high turnover numbers, make use of earth-abundant materials. In this Highlight we focus on a recent example in which a copper-based photosensitizer is used, in combination with an iron-based catalyst for light-driven proton reduction.

The LISA application, developed by the University Hospitals Leuven, permits referring physicians to consult the electronic medical records of their patients over the internet in a highly secure way. We decided to completely change the way we secured the application, discard the existing web application and build a completely new application, based on the in-house developed hospital information system, used in the University Hospitals Leuven. The result is a fat Java client, running on a Windows Terminal Server, secured by a commercial SSL-VPN solution.

We argue that efficient access to digital images for the Intensive Care Unit (ICU) requires the PACS to be strongly integrated within the overall working environment. This includes tailoring the imaging environment towards the specific working organization as well as integrating it with the HIS. The purpose of this project was to implement an integrated environment for chest images generated using a recently introduced phosphorplate scanner. PACS-HIS-Modality integration is reflected in our environment in different ways. The user interface of the viewing station is centered around often used patterns in ICU viewing. Information about bed occupancy is retrieved from the HIS and exploited in the viewing station. A digital connection between the phosphorplate scanner and the HIS ensures that images are correctly related to other patient information and to previous images of the patient. Using minor adaptations to the existing HIS, PACS and HIS have been made to cooperate in integrated presentation of images and reports. As work in progress, this integration has been expanded towards hypermedia, linking annotations in images to sections in a textual or spoken report. We discuss the relation between PACS and the global information environment, emphasizing organizational issues rather than technological aspects.© (1996) COPYRIGHT SPIE--The International Society for Optical Engineering. Downloading of the abstract is permitted for personal use only.

We report on our experience with a recently introduced phosphorplate system (AGFA Diagnostic Center) from the viewpoint of overall operation efficiency. A first factor that determines efficiency is the time it takes to enter patient and examination information. A second factor is robustness of the automated image processing algorithms provided in the CR, as this determines the need for interactive image reprocessing on the workstation or for film retake. Both factors are strongly influenced by the integration of the modality within the HIS, whereby information about the patient and the examination request is automatically transferred to the phosphorplate system. Problems related to wrongly entered patient information are virtually eliminated. In comparison with manual entry of patient demographic data, efficiency has increased significantly. The examination information provided by the HIS helps the CR system to select optimal processing parameters automatically in the majority of situations. Furthermore, the image processing algorithms turn out to be rather robust and independent of pathology. We believe that both the HIS connection and the robustness of internal image processing contribute to making the current percentage of retakes and reprocessing in the order of 1.2% and 0.9% respectively, compared to more than 8% of retakes in the previous analogue systems.