A service oriented architecture to implement clinical guidelines for evidence-based medical practice

Health information technology (HIT) has been identified as the fundamental driver to streamline the healthcare delivery processes to improve care quality and reduce operational costs. Of the many facets of HIT is Clinical Decision Support (CDS) which provides the physician with patient-specific inferences, intelligently filtered and organized, at appropriate times. This research has been conducted to develop an agile solution to Clinical Decision Support at the point of care in a healthcare setting as a potential solution to the challenges of interoperability and the complexity of possible solutions. The capabilities of Business Process Management (BPM) and Workflow Management systems are leveraged to support a Service Oriented Architecture development approach for ensuring evidence based medical practice. The aim of this study is to present an architecture solution that is based on SOA principles and embeds clinical guidelines within a healthcare setting. Since the solution is designed to implement real life healthcare scenarios, it essentially supports evidence-based clinical guidelines that are liable to change over a period of time. The thesis is divided into four parts. The first part consists of an Introduction to the study and a background to existing approaches for development and integration of Clinical Decision Support Systems. The second part focuses on the development of a Clinical Decision Support Framework based on Service Oriented Architecture. The CDS Framework is composed of standards based open source technologies including JBoss SwitchYard (enterprise service bus), rule-based CDS enabled by JBoss Drools, process modelling using Business Process Modelling and Notation. To ensure interoperability among various components, healthcare standards by HL7 and OMG are implemented. The third part provides implementation of this CDS Framework in healthcare scenarios. Two scenarios are concerned with the medical practice for diagnosis and early intervention (Chronic Obstructive Pulmonary Disease and Lung Cancer), one case study for Genetic data enablement of CDS systems (New born screening for Cystic Fibrosis) and the last case study is about using BPM techniques for managing healthcare organizational perspectives including human interaction with automated clinical workflows. The last part concludes the research with contributions in design and architecture of CDS systems. This thesis has primarily adopted the Design Science Research Methodology for Information Systems. Additionally, Business Process Management Life Cycle, Agile Business Rules Development methodology and Pattern-Based Cycle for E-Workflow Design for individual case studies are used. Using evidence-based clinical guidelines published by UK’s National Institute of Health and Care Excellence, the integration of latest research in clinical practice has been employed in the automated workflows. The case studies implemented using the CDS Framework are evaluated against implementation requirements, conformance to SOA principles and response time using load testing strategy. For a healthcare organization to achieve its strategic goals in administrative and clinical practice, this research has provided a standards based integration solution in the field of clinical decision support. A SOA based CDS can serve as a potential solution to complexities in IT interventions as the core data and business logic functions are loosely coupled from the presentation. Additionally, the results of this this research can serve as an exemplar for other industrial domains requiring rapid response to evolving business processes

A service oriented approach for guidelines-based clinical decision support using BPMN

Evidence-based medical practice requires that clinical guidelines need to be documented in such a way that they represent a clinical workflow in its most accessible form. In order to optimize clinical processes to improve clinical outcomes, we propose a Service Oriented Architecture (SOA) based approach for implementing clinical guidelines that can be accessed from an Electronic Health Record (EHR) application with a Web Services enabled communication mechanism with the Enterprise Service Bus. We have used Business Process Modelling Notation (BPMN) for modelling and presenting the clinical pathway in the form of a workflow. The aim of this study is to produce spontaneous alerts in the healthcare workflow in the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The use of BPMN as a tool to automate clinical guidelines has not been previously employed for providing Clinical Decision Support (CDS)

The exploration of mystical experiences among religious preachers

The current qualitative study aimed to explore the mystical experiences among religious preachers. A purposive sampling technique was employed to select a sample of (n=10) religious preachers who had encountered at least one mystical experience. The transcendental phenomenological approach was used to capture the essence of the mystical experiences through an in-depth semi-structured interview guide based on five domains: the exploration of mystic features, beliefs, impact on life, sharing of mystical experiences, and the religious and cultural oriented explanations. The modification of Stevick-Colaizzi-Keen’s model by Maustakas (1994) was employed for data analysis followed through a series of steps such as bracketing, horizonalization of data, a grouping of significant statements to constitute themes (triggers, perceptual experience, symbolism and derived meanings, significant figures, reaction, and the cultural explanation of mystical experiences), textural description and a structural description with verbatim examples was developed. These descriptions were combined to write a composite description that reflected the ‘essence’ of the mystical experiences and highlighted the causes, characteristics, perceptual experiences, beliefs, and impact. The findings highlighted the subjective nature of the mystical experiences and the need to develop an indigenous formal criterion to identify such experiences

Ovarian pregnancy: an unusual presentation

Ovarian pregnancy is a rare type of ectopic pregnancy and usually, it ends with rupture before the end of the first trimester. The clinical picture generally mimics that of ruptured tubal ectopic pregnancy and hemorrhagic ovarian cyst. Transvaginal sonography may be helpful. We report a rare primary ruptured ovarian pregnancy in a 23 years lady

Knowledge and skills in community oriented medical education (COME)self-ratings of medical undergraduates in Karachi

Objective: To assess the satisfaction of medical students regarding community oriented knowledge and skills that are proposed to be part of the current undergraduate medical curriculum. Methods: Competencies listed in the regulations for medical education designed by the Pakistan Medical and Dental Council (PMDC) were used to develop a self-administered questionnaire. Using the questionnaire 220 final year students of 3 public sector medical schools self-rated the knowledge and skills that should be part of the curriculum. For analysis the questions were grouped into courses of Basic, Clinical and Community Health Sciences. Students ranked their perceptions on a Likert scale of 0-4 for each question. Descriptive analysis was done to calculate the proportion of satisfied and dissatisfied students using the median of the highest possible score as the cut off. Results: The analysis of knowledge gained found a greater proportion of satisfied students with the Basic (55.9%) and Clinical Sciences (50.9%) courses than the Community Health Sciences course (45.5%). Analysis of skills acquired uniformly showed a low percentage of satisfied students for Basic (39.1%), Clinical (29.7%) and Community Health Sciences (19.1%). The proportion of students dissatisfied with their knowledge and skills for different courses ranged from 38.2-85%. Conclusion: Students perceive that current medical school curricula are unable to meet the required standards. Proper implementation of community oriented curricula is the first step towards effective health care provisio

Posebnosti vodstva kao preokret sestrinstva: Potreba za osobne i organizacijske identifikacije Authentic leadership and nurses’ turnover intentions: The role of personal and organizational identification

Ova studija pruža informacije o autentičnom vodstvu, osobnoj i organizacijskoj identifikaciji te namjerama slobode kretanja medicinskih sestara/tehničara, kao i njihovom međusobnom odnosu u Pakistanu. Predlažemo da osobna i organizacijska identifikacija posreduju učinku autentičnog vodstva na namjere skrbništva medicinskih sestara/tehničara. Za svrhe ispitivanja osmišljena je kvantitativna presječna vrsta studije. Uključeno je 432 registriranih medicinskih sestara/tehničara koji rade u privatnim bolnicama Pakistana. Rezultati ukazuju na to da autentično vodstvo u sestrinstvu smanjuje namjere odlazaka medicinskih sestara/tehničara istodobno poboljšavaju i osobnu i organizacijsku identifikaciju te djeluju kao negativan čimbenik na odlazak iz strukovnosti. Utjecaj autentičnog vodstva na namjere odlazaka medicinskih sestara/tehničara iz struke upućuje na to da bi praksa bolničkog upravljanja ljudskim resursima trebala staviti naglasak na autentične značajke vodstva u razvoju sestrinstva

COMPARE THE INTENDED RESULT OF SINGLE BOLUS INTRAVENOUS LIGNOCAINE WITH MAGNESIUM SULPHATE TO REDUCE THE PRESSURE OF AVAILABILITY OF OXYGEN TO TISSUES DURING LARYNGOSCOPY AND INTUBATION

Background: Placement of flexible plastic tube into trachea to maintain an open airway is done during general anesthesia and its effect availability of oxygen to tissue in patients. Objectives: The aim of this study was to compare the intended result of single bolus intravenous lignocaine with magnesium sulphate to reduce the pressure of availability of oxygen to tissues during laryngoscopy and intubation. Material and Methods: There were 178 patients included in this study. Two groups were made with 89 patients each. Group A receive intravenous 1% lignocaine 1mg/kg. Group B receive intravenous magnesium sulphate 10mg/kg. the data about mean arterial pressure, heart rate was compared between 2 groups. Data was analyzed wing SPSS version 22. Place of study. 1st March, 2018 to 31ST August, 2018 in Jinnah Hospital. Lahore. Duration of study: Time period for this study was 6 months. Result: In 54% patients of group A, 20% reduction of mean Arterial pressure was observed and 36.69% reduction in group B. there was 25% reduction in heart rate from basilines values in 11% patients of group A and 6.23% in that of group B. Conclusion: Comparative study showed that lignocaine was more effective than magnesium sulphate by preventing increase in HR and MAP after intubation and laryngoscopy. Keywords: Hemodynamic changes, MAP, HR, Stress response

Perioperative registries in resource-limited settings: The way forward for Pakistan

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical records and high loss-to-follow-up rates, requiring telemedicine initiatives as an adjunct to existing care for the assessment of post-discharge outcomes. Lastly, standardised coding of clinical terminology is warranted for ensuring interoperability of the registries for which adaptation of the existing disease and procedural codes can be a sustainable and cost-effective alternative to the development of new codes

Gaba-B Encephalitis in Pakistan: A Rare but Treatable Entity

Autoimmune and paraneoplastic encephalitides are a group of neurologic disorders that present with cognitive decline, neuropsychiatric symptoms, movement disorders, or seizures. These diseases can present before, with, or after the diagnosis of malignancy. We report two cases of GABA-B encephalitis from Pakistan. The first patient was a 67-year-old gentleman presented with cognitive decline and neuropsychiatric symptoms. His CSF analysis showed increased protein levels and GABA-B receptor antibodies. He was treated with pulse steroids, which improved his symptoms. The second patient was a 34-year-old lady with cognitive decline and psychomotor symptoms. Her serum autoimmune antibody panel showed antibodies against GABA-B receptors. She was treated with pulse steroids followed by plasma exchange, but did not improve. A low threshold should be kept for testing for autoimmune and paraneoplastic encephalitides because they are potentially treatable

Isolation of thymoquinone from Nigella sativa L. and Thymus vulgaris L., and its anti-proliferative effect on HeLa cancer cell lines

Purpose: To isolate thymoquinone (TQ) from Nigella sativa L. and Thymus vulgaris L., and investigate its anti-proliferative effect on HeLa cancer cells.Method: Pulverized dried samples of N. sativa seed (100 g) and aerial parts of T. vulgaris (1000 g) were subjected to Soxhlet extraction using methanol and n-hexane combined in different proportions. Thymoquinone (TQ) was then isolated from the extracts using high performance liquid chromatography (HPLC). The isolated TQ was further subjected to Fourier Transform Infrared (FTIR) spectroscopy to identify its functional groups. The anti-proliferative effect of TQ on HeLa cancer cells was evaluated using 3-[4, 5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay.Results: Extract yield from N. sativa was significantly higher than from T. vulgaris, and also increased with increase in the proportion of methanol in the extraction solvent (p < 0.05). Methanol and n-hexane (4:1, v:v) yielded the highest amount of oil, with yields of 15.8 and 9.7 ml/25 g dry weight (d.wt.) from N. sativa and T. vulgaris, respectively. The results obtained from HPLC showed that the concentration of TQ isolated from N. sativa (388.61 μg/ml) was significantly higher than that from T. vulgaris (357.03 μg/ml, p < 0.05). The anti-proliferative effects of TQ standard and TQ isolated from N. sativa on HeLa cancer cells were dose-dependent, and was highest at the lowest concentration. The number of viable cells significantly decreased with increase in TQ concentration (p < 0.01). TQ from N. sativa significantly reduced the number of viable cells even at the lowest concentration when compared to TQ standard (p < 0.05). Cell death was significantly higher in TQ-treated groups than in untreated cancer cells.Conclusion: The results obtained in this study show that N. sativa is a potential source of TQ, with the yield enhanced by modifying the extraction procedure or solvent used. Furthermore, TQ isolated from N. sativa exerts a dose-dependent anti-proliferative effect on HeLa cancer cells.Keywords: Thymoquinone, Nigella sativa, Thymus vulgaris, Anti-proliferative effec