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Introduction Noninvasive positive pressure ventilation (NIPPV) plays an important role in the management of respiratory failure. However, since the emergence of the COVID-19 pandemic, utilization of traditional face mask NIPPV has been curtailed in part due to risk of aerosolization of respiratory particles and subsequent health care worker exposure. A randomized clinical trial in 2016 reported that an alternative interface, helmet NIPPV, may be more effective than traditional NIPPV at preventing intubation and improving mortality. The helmet NIPPV interface provides positive airway pressure, while also theoretically minimizing aerosolization, making it a feasible modality in management of respiratory failure in COVID-19 patients. Case and outcomes This report describes a single-center experience of a series of three COVID-19 patients with hypoxemic respiratory failure managed with helmet NIPPV. One patient was able to avoid intubation while a second patient was successfully extubated to NIPPV. Ultimately, the third patient was unable to avoid intubation with helmet NIPPV, although the application of the device was late in the progression of the disease. Discussion NIPPV is an important modality in the management of respiratory failure and has been shown to reduce the need for immediate endotracheal intubation in select populations. For patients unable to tolerate facemask NIPPV, the helmet provides an alternate interface. In COVID-19 patients, the helmet interface may reduce the risk of virus exposure to health care workers from aerosolization. Based on this experience, we recommend that helmet NIPPV can be considered as a feasible option for the management of patients with COVID-19, whether the goal is to prevent immediate intubation or avoid post-extubation respiratory failure. Randomized studies are needed to definitively validate the use of helmet NIPPV in this population. Conclusion Helmet NIPPV is a feasible therapy to manage COVID-19 patients.

Objectives: To reflect on the history, status, and future trends of decision support in health and biomedical informatics. To highlight the new challenges posed by the complexity and diversity of genomic and clinical domains. To examine the emerging paradigms for supporting cost-effective, personalized decision making.Methods: A group of international experts in health and biomedical informatics presented their views and discussed the challenges and issues on decision support at the Methods of Information in Medicine 50th anniversary symposium. The experts were invited to write short articles summarizing their thoughts and positions after the symposium.Results and Conclusions: The challenges posed by the complexity and diversity of the domain knowledge, system infrastructure, and usage pattern are highlighted. New requirements and computational paradigms for representing, using, and acquiring biomedical knowledge and healthcare protocols are proposed. The underlying common themes identified for developing next-generation decision support include incorporating lessons from history, uniform vocabularies, integrative interfaces, contextualized decisions, personalized recommendations, and adaptive solutions. [ABSTRACT FROM AUTHOR]

Life span can be extended in rodents by restricting food availability (caloric restriction [CR]) or by providing food low in methionine (Meth-R). Here, we show that a period of food restriction limited to the first 20 days of life, via a 50% enlargement of litter size, shows extended median and maximal life span relative to mice from normal sized litters and that a Meth-R diet initiated at 12 months of age also significantly increases longevity. Furthermore, mice exposed to a CR diet show changes in liver messenger RNA patterns, in phosphorylation of Erk, Jnk2, and p38 kinases, and in phosphorylation of mammalian target of rapamycin and its substrate 4EBP1, HE-binding protein 1 that are not observed in liver from age-matched Meth-R mice. These results introduce new protocols that can increase maximal life span and suggest that the spectrum of metabolic changes induced by low-calorie and low-methionine diets may differ in instructive ways. [ABSTRACT FROM AUTHOR]

Biogerontologists and demographers have argued that the fastest, most cost-effective strategies for prevention of the medical problems that afflict those older than 60 years are likely to emerge from a deeper understanding of what factors time the aging process and how aging leads, in rough synchrony, to the many diseases and disabilities of aging. Biologists can support and refine this discussion by studies of slow-aging mice, of mice with disease-promoting mutations, of mice in which specific cellular responses have been abrogated by genetic or pharmaceutical interventions, of slow-aging dog and horse breeds, and of the factors, genetic and physiological, that coordinate lethal and nonlethal consequences of aging in people. More work is also needed to learn how timing of antiaging interventions can be used to optimize the balance between beneficial and undesirable effects. [ABSTRACT FROM AUTHOR]

Prediction of individual life span based on characteristics evaluated at middle-age represents a challenging objective for aging research. In this study, we used machine learning algorithms to construct models that predict life span in a stock of genetically heterogeneous mice. Life-span prediction accuracy of 22 algorithms was evaluated using a cross-validation approach, in which models were trained and tested with distinct subsets of data. Using a combination of body weight and T-cell subset measures evaluated before 2 years of age, we show that the life-span quartile to which an individual mouse belongs can be predicted with an accuracy of 35.3% (+/-0.10%). This result provides a new benchmark for the development of life-span-predictive models, but improvement can be expected through identification of new predictor variables and development of computational approaches. Future work in this direction can provide tools for aging research and will shed light on associations between phenotypic traits and longevity. [ABSTRACT FROM AUTHOR]

Objective: Evaluations of individual terminology systems should be driven in part by the intended usages of such systems. Clinical interface terminologies support interactions between healthcare providers and computer-based applications. They aid practitioners in converting clinical "free text" thoughts into the structured, formal data representations used internally by application programs. Interface terminologies also serve the important role of presenting existing stored, encoded data to end users in human-understandable and actionable formats. The authors present a model for evaluating functional utility of interface terminologies based on these intended uses.Design: Specific parameters defined in the manuscript comprise the metrics for the evaluation model.Measurements: Parameters include concept accuracy, term expressivity, degree of semantic consistency for term construction and selection, adequacy of assertional knowledge supporting concepts, degree of complexity of pre-coordinated concepts, and the "human readability" of the terminology. The fundamental metric is how well the interface terminology performs in supporting correct, complete, and efficient data encoding or review by humans.Results: Authors provide examples demonstrating performance of the proposed evaluation model in selected instances.Conclusion: A formal evaluation model will permit investigators to evaluate interface terminologies using a consistent and principled approach. Terminology developers and evaluators can apply the proposed model to identify areas for improving interface terminologies. [ABSTRACT FROM AUTHOR]

Background Up to 38% of inpatient medication errors occur at the administration stage. Although they reduce prescribing errors, computerized provider order entry (CPOE) systems do not prevent administration errors or timing discrepancies. This study determined the degree to which CPOE medication orders matched actual dose administration times. METHODS At a 658-bed academic hospital with CPOE but lacking electronic medication administration charting, authors randomly selected adult patients with eligible medication orders from historical 1999-2003 CPOE log files. Retrospective manual chart audits compared expected (from CPOE) and actual timing of medication administrations. Outcomes included: dose omissions, median lag times between ordered and charted administrations, unauthorized doses, wrong dose errors, and the rate of nurses' medication schedule shifting. RESULTS Dose omissions occurred in 756 of 6019 (12.6%) audited administration opportunities; only 313 of the omissions (5.2% of opportunities) were unexplained. Wrong doses and unexpected doses occurred for 0.1% and 0.7% of opportunities, respectively. Median lag from expected first dose to actual charted administration time was 27 minutes (IQR 0-127). Nursing staff shifted from ordered to alternate administration schedules for 10.7% of regularly scheduled recurring medication orders. Chart review identified reasons for dose omissions, delays, and dose shifting. CONCLUSION Inpatient CPOE orders are legible and conveyed electronically to nurses and the pharmacy. Nonetheless, ward-based medication administrations do not consistently occur as ordered. Medication administration discrepancies are likely to persist even after implementing CPOE and bar-coded medication administration unless recommended interventions are made to address issues such as determining the true urgency of medication administration, avoiding overlapping duplicative medication orders, and developing a safe means for shifting dosing schedules. [ABSTRACT FROM AUTHOR]

Objective: Hyperglycemia worsens clinical outcomes in critically ill patients. Precise glycemia control using intravenous insulin improves outcomes. To determine if we could improve glycemia control over a previous paper-based, manual protocol, authors implemented, in a surgical intensive care unit (SICU), an intravenous insulin protocol integrated into a care provider order entry (CPOE) system.Design: Retrospective before-after study of consecutive adult patients admitted to a SICU during pre (manual protocol, 32 days) and post (computer-based protocol, 49 days) periods.Measurements: Percentage of glucose readings in ideal range of 70-109 mg/dl, and minutes spent in ideal range of control during the first 5 days of SICU stay.Results: The computer-based protocol reduced time from first glucose measurement to initiation of insulin protocol, improved the percentage of all SICU glucose readings in the ideal range, and improved control in patients on IV insulin for > or =24 hours. Hypoglycemia (<40 mg/dl) was rare in both groups.Conclusion: The CPOE-based intravenous insulin protocol improved glycemia control in SICU patients compared to a previous manual protocol, and reduced time to insulin therapy initiation. Integrating a computer-based insulin protocol into a CPOE system achieved efficient, safe, and effective glycemia control in SICU patients. [ABSTRACT FROM AUTHOR]

Previous investigators have defined clinical interface terminology as a systematic collection of health care-related phrases (terms) that supports clinicians' entry of patient-related information into computer programs, such as clinical "note capture" and decision support tools. Interface terminologies also can facilitate display of computer-stored patient information to clinician-users. Interface terminologies "interface" between clinicians' own unfettered, colloquial conceptualizations of patient descriptors and the more structured, coded internal data elements used by specific health care application programs. The intended uses of a terminology determine its conceptual underpinnings, structure, and content. As a result, the desiderata for interface terminologies differ from desiderata for health care-related terminologies used for storage (e.g., SNOMED-CT), information retrieval (e.g., MeSH), and classification (e.g., ICD9-CM). Necessary but not sufficient attributes for an interface terminology include adequate synonym coverage, presence of relevant assertional knowledge, and a balance between pre- and post-coordination. To place interface terminologies in context, this article reviews historical goals and challenges of clinical terminology development in general and then focuses on the unique features of interface terminologies. [ABSTRACT FROM AUTHOR]

Objective: In the context of an inpatient care provider order entry (CPOE) system, to evaluate the impact of a decision support tool on integration of cardiology "best of care" order sets into clinicians' admission workflow, and on quality measures for the management of acute myocardial infarction (AMI) patients.Design: A before-and-after study of physician orders evaluated (1) per-patient use rates of standardized acute coronary syndrome (ACS) order set and (2) patient-level compliance with two individual recommendations: early aspirin ordering and beta-blocker ordering.Measurements: The effectiveness of the intervention was evaluated for (1) all patients with ACS (suspected for AMI at the time of admission) (N = 540) and (2) the subset of the ACS patients with confirmed discharge diagnosis of AMI (n = 180) who comprise the recommended target population who should receive aspirin and/or beta-blockers. Compliance rates for use of the ACS order set, aspirin ordering, and beta-blocker ordering were calculated as the percentages of patients who had each action performed within 24 hours of admission.Results: For all ACS admissions, the decision support tool significantly increased use of the ACS order set (p = 0.009). Use of the ACS order set led, within the first 24 hours of hospitalization, to a significant increase in the number of patients who received aspirin (p = 0.001) and a nonsignificant increase in the number of patients who received beta-blockers (p = 0.07). Results for confirmed AMI cases demonstrated similar increases, but did not reach statistical significance.Conclusion: The decision support tool increased optional use of the ACS order set, but room for additional improvement exists. [ABSTRACT FROM AUTHOR]

Background: Unintended consequences of computerized patient care system interventions may increase resource use, foster clinical errors, and reduce users' confidence.Objective: To evaluate three successive interventions designed to reduce serum magnesium test ordering through a care provider order entry system (CPOE). The second, modeled after a previously successful intervention, caused paradoxical increases in magnesium test ordering rates.Design: A time-series analysis modeled weekly rates of magnesium test ordering, underlying trends, the impact of the three successive interventions, and the impact of potential covariates. The first intervention exhorted users to discontinue unnecessary tests recurring more than 72 hours into the future. The second displayed recent magnesium, calcium, and phosphorus test results, limited testing to one test instance per order, and provided education regarding appropriate indications for testing. The third targeted only magnesium ordering, displayed recent results, limited testing to one instance per order, summarized indications for testing, and required users to select an indication.Participants: Clinicians at Vanderbilt University Hospital, a 609-bed academic inpatient tertiary care facility, from 1998 through 2003.Measurements: Weekly rates of new serum magnesium test orders, instances, and results.Results: At baseline, there were 539 magnesium tests ordered per week. This decreased to 380 (p = 0.001) per week after the first intervention, increased to 491 per week (p < 0.001) after the second, and decreased to 276 per week (p < 0.001) after the third.Conclusion: A clinical decision support intervention intended to regulate testing increased test order rates as an unintended result of decision support. CPOE implementers must carefully design resource-related interventions and monitor their impact over time. [ABSTRACT FROM AUTHOR]

Objective: Authors evaluated whether displaying context sensitive links to infrequently accessed educational materials and patient information via the user interface of an inpatient computerized care provider order entry (CPOE) system would affect access rates to the materials.Design: The CPOE of Vanderbilt University Hospital (VUH) included "baseline" clinical decision support advice for safety and quality. Authors augmented this with seven new primarily educational decision support features. A prospective, randomized, controlled trial compared clinicians' utilization rates for the new materials via two interfaces. Control subjects could access study-related decision support from a menu in the standard CPOE interface. Intervention subjects received active notification when study-related decision support was available through context sensitive, visibly highlighted, selectable hyperlinks.Measurements: Rates of opportunities to access and utilization of study-related decision support materials from April 1999 through March 2000 on seven VUH Internal Medicine wards.Results: During 4,466 intervention subject-days, there were 240,504 (53.9/subject-day) opportunities for study-related decision support, while during 3,397 control subject-days, there were 178,235 (52.5/subject-day) opportunities for such decision support, respectively (p = 0.11). Individual intervention subjects accessed the decision support features at least once on 3.8% of subject-days logged on (278 responses); controls accessed it at least once on 0.6% of subject-days (18 responses), with a response rate ratio adjusted for decision support frequency of 9.17 (95% confidence interval 4.6-18, p < 0.0005). On average, intervention subjects accessed study-related decision support materials once every 16 days individually and once every 1.26 days in aggregate.Conclusion: Highlighting availability of context-sensitive educational materials and patient information through visible hyperlinks significantly increased utilization rates for study-related decision support when compared to "standard" VUH CPOE methods, although absolute response rates were low. [ABSTRACT FROM AUTHOR]

Background: Laboratory testing of hospitalized patients, although essential, can be expensive and sometimes excessive. Attempts to reduce unnecessary testing have often been difficult to implement or sustain.Objective: Use of peer management through a resource utilization committee (RUC) to favorably modify test-ordering behavior in a large academic medical center.Design: Interrupted time-series study.Setting: Medical center with inpatient care provider order entry (CPOE) system and database of ordered tests.Participants: Predominantly housestaff physicians but all clinical staff (attending physicians, housestaff, medical students, nurses, advance practice nurses, and other clinical staff) at Vanderbilt University Hospital who used CPOE systems.Intervention: The RUC analyzed the ordering habits of providers during previous years and made 2 interventions by modifying software for the CPOE system. The committee first initiated a daily prompt in the system that asked providers whether they wanted to discontinue tests scheduled beyond 72 hours. After evaluating this first intervention, the committee further constrained testing options by unbundling serum metabolic panel tests (sodium, potassium, chloride, bicarbonate, glucose, blood urea nitrogen, and creatinine tests) into single components and by reducing the ease of repeating targeted tests (including electrolyte, blood urea nitrogen, creatinine, and glucose tests; electrocardiography; and portable chest radiography).Measurements: Pre- and postintervention volumes of tests; proportion of patients with abnormal targeted chemistry levels after 48 hours; rates of repeated admission, transfer to intensive care units, and mortality; adjusted coefficient of variation for test ordering; and length of stay.Results: Voluntary reduction of testing beyond 72 hours (first intervention) decreased orders for metabolic panel component tests by 24% (P = 0.02) and electrocardiograms by 57% (P = 0.006) but not orders for portable chest radiographs. Prospective constraints on recurrent test ordering with panel unbundling (second intervention) produced an additional decrease of 51% for metabolic panel component tests (P < 0.001) and 16% for portable chest radiographs (P = 0.03). Incidence of patients with abnormal targeted blood chemistry levels after 48 hours decreased after the intervention (P = 0.02). Postintervention-adjusted coefficients of variation decreased for metabolic panel component tests (P = 0.03) and electrocardiography (P = 0.04). Rates of (adjusted) monthly readmission, transfers to intensive care units, hospital length of stay, and mortality were unchanged.Limitations: Other activities occurring during the time period of the interventions might have influenced some test-ordering behaviors, and we assessed effects on only a limited number of commonly ordered tests.Conclusions: Peer management reduced provider variability by addressing the imperfect ability of clinicians to rescind testing in a timely manner. Hospitals with growing health care costs can improve their resource utilization through peer management of testing behaviors by using CPOE systems. [ABSTRACT FROM AUTHOR]

Care providers' adoption of computer-based health-related documentation ('note capture') tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe the development and evaluation of computational tools to identify concepts within medical curricular documents, using information derived from the National Library of Medicine's Unified Medical Language System (UMLS). The long-term goal of the KnowledgeMap (KM) project is to provide faculty and students with an improved ability to develop, review, and integrate components of the medical school curriculum. DESIGN: The KM concept identifier uses lexical resources partially derived from the UMLS (SPECIALIST lexicon and Metathesaurus), heuristic language processing techniques, and an empirical scoring algorithm. KM differentiates among potentially matching Metathesaurus concepts within a source document. The authors manually identified important 'gold standard' biomedical concepts within selected medical school full-content lecture documents and used these documents to compare KM concept recognition with that of a known state-of-the-art 'standard'-the National Library of Medicine's MetaMap program. MEASUREMENTS: The number of 'gold standard' concepts in each lecture document identified by either KM or MetaMap, and the cause of each failure or relative success in a random subset of documents. RESULTS: For 4,281 'gold standard' concepts, MetaMap matched 78% and KM 82%. Precision for 'gold standard' concepts was 85% for MetaMap and 89% for KM. The heuristics of KM accurately matched acronyms, concepts underspecified in the document, and ambiguous matches. The most frequent cause of matching failures was absence of target concepts from the UMLS Metathesaurus. CONCLUSION: The prototypic KM system provided an encouraging rate of concept extraction for representative medical curricular texts. Future versions of KM should be evaluated for their ability to allow administrators, lecturers, and students to navigate through the medical curriculum to locate redundancies, find interrelated information, and identify omissions. In addition, the ability of KM to meet specific, personal information needs should be assessed. [ABSTRACT FROM AUTHOR]

Chloroprene (2-chloro-1,3-butadiene) is a high production chemical used almost exclusively in the production of polychloroprene (neoprene) elastomer, Because of its structural similarity to 1,3-butadiene, a trans-species carcinogen, inhalation studies were performed with chloroprene to evaluate its carcinogenic potential in rats and mice. Groups of 50 male and female F344/N rats and 50 male and female B6C3F1 mice were exposed to 0, 12.8, 32 or 80 p.p.m. chloroprene (6 h/day, 5 days/week) for 2 years. Under these conditions, chloroprene was carcinogenic to the oral cavity, thyroid gland, lung, kidney and mammary gland of rats, and to the lung, circulatory system (hemiangiomas, and hemangiosarcomas), Harderian gland, kidney, forestomach, liver, mammary gland, skin, mesentery and Zymbal's gland of mice. Survival adjusted tumor rates in mice were fit to a Weibull model for estimation of the shape of the dose-response curves, estimation of ED10 values (the estimated exposure concentration associated with an increased cancer risk of 10%) and comparison of these parameters with those for 1,3-butadiene. Butadiene has been identified as a potent carcinogen in mice and has been associated with increased risk of lymphatic and hematopoietic cancer in exposed workers. Shape parameter values for most of the neoplastic effects of chloroprene and 1,3-butadiene were consistent with linear or supralinear responses in the area near the lowest tested exposures. The most potent carcinogenic effect of 1,3-butadiene was the induction of lung neoplasms in female mice, which had an ED10 value of 0.3 p.p.m. Since the ED10 value for that same response in chloroprene exposed mice was also 0.3 p.p.m., we conclude that the carcinogenic potency of chloroprene in mice is similar to that of 1,3-butadiene. Cancer potency of chloroprene is greater in the mouse lung than in the rat lung, but greater in the rat kidney than in the mouse kidney and nearly equivalent in the mammary gland of each species. [ABSTRACT FROM PUBLISHER]

Articles about medical diagnostic decision support (MDDS) systems often begin with a disclaimer such as, "despite many years of research and millions of dollars of expenditures on medical diagnostic systems, none is in widespread use at the present time." While this statement remains true in the sense that no single diagnostic system is in widespread use, it is misleading with regard to the state of the art of these systems. Diagnostic systems, many simple and some complex, are now ubiquitous, and research on MDDS systems is growing. The nature of MDDS systems has diversified over time. The prospects for adoption of large-scale diagnostic systems are better now than ever before, due to enthusiasm for implementation of the electronic medical record in academic, commercial, and primary care settings. Diagnostic decision support systems have become an established component of medical technology. This paper provides a review and a threaded bibliography for some of the important work on MDDS systems over the years from 1954 to 1993. [ABSTRACT FROM AUTHOR]