Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

<p>Abstract</p> <p>Background</p> <p>Acute medical care often demands timely, accurate decisions in complex situations. Computerized clinical decision support systems (CCDSSs) have many features that could help. However, as for any medical intervention, claims that CCDSSs improve care processes and patient outcomes need to be rigorously assessed. The objective of this review was to systematically review the effects of CCDSSs on process of care and patient outcomes for acute medical care.</p> <p>Methods</p> <p>We conducted a decision-maker-researcher partnership systematic review. MEDLINE, EMBASE, Evidence-Based Medicine Reviews databases (Cochrane Database of Systematic Reviews, DARE, ACP Journal Club, and others), and the Inspec bibliographic database were searched to January 2010, in all languages, for randomized controlled trials (RCTs) of CCDSSs in all clinical areas. We included RCTs that evaluated the effect on process of care or patient outcomes of a CCDSS used for acute medical care compared with care provided without a CCDSS. A study was considered to have a positive effect (<it>i.e.</it>, CCDSS showed improvement) if at least 50% of the relevant study outcomes were statistically significantly positive.</p> <p>Results</p> <p>Thirty-six studies met our inclusion criteria for acute medical care. The CCDSS improved process of care in 63% (22/35) of studies, including 64% (9/14) of medication dosing assistants, 82% (9/11) of management assistants using alerts/reminders, 38% (3/8) of management assistants using guidelines/algorithms, and 67% (2/3) of diagnostic assistants. Twenty studies evaluated patient outcomes, of which three (15%) reported improvements, all of which were medication dosing assistants.</p> <p>Conclusion</p> <p>The majority of CCDSSs demonstrated improvements in process of care, but patient outcomes were less likely to be evaluated and far less likely to show positive results.</p

Cell Cycle Studies on the Human Nek3, Nek5 and Nek11 Protein Kinases

The NIMA-related kinases represent a family of serine/threonine protein kinases implicated in cell cycle control and ciliogenesis. The founding member of this family, the NIMA kinase of Aspergillus nidulans, contributes to multiple aspects of mitotic progression including the timing of mitotic entry, chromatin condensation, spindle organisation and mitotic exit. Mammals contain a family of eleven NIMA related kinases, named Nek1 to Nek11. Of these, to date there is substantial evidence that Nek2, Nek6, Nek7 and Nek9 regulate mitotic spindle formation, while Nek1 and Nek8 are implicated in microtubule organisation in non-dividing cells during ciliogenesis. The common underlying theme between spindle formation and ciliogenesis is the role of microtubules and microtubule organising centres. Hence, the emerging hypothesis is that all Neks may play a role in the organisation of microtubules. However, for several Neks, little if any information is available. In this thesis, I therefore began to examine the properties of three less well researched human Neks, Nek3, Nek5 and Nek11. First of all, antibodies against each of these kinases were generated or characterised. This allowed a broad study of the localisation, expression and activity of these kinases. Intriguingly, Nek3, Nek5 and Nek11 were all localised to centrosomes. Based on these results a more detailed study was performed with human Nek5 for which there is currently no published data. Human Nek5 is a nuclear protein that localises to the centrosomes during interphase, spindle poles during early mitosis, and to basal bodies in mono- ciliated cells. Specifically, Nek5 localised at the proximal ends of centrioles peaking in intensity in early mitosis. Importantly, siRNA-mediated depletion of Nek5 results in premature centrosome splitting and loss of centrosomal γ-tubulin. Hence, Nek5 is uncovered as a potential player in the negative regulation of centrosome separation

Cell cycle studies on the human Nek3, Nek5 and Nek11 protein kinases

The NIMA-related kinases represent a family of serine/threonine protein kinases implicated in cell cycle control and ciliogenesis. The founding member of this family, the NIMA kinase of Aspergillus nidulans, contributes to multiple aspects of mitotic progression including the timing of mitotic entry, chromatin condensation, spindle organisation and mitotic exit. Mammals contain a family of eleven NIMA related kinases, named Nek1 to Nek11. Of these, to date there is substantial evidence that Nek2, Nek6, Nek7 and Nek9 regulate mitotic spindle formation, while Nek1 and Nek8 are implicated in microtubule organisation in non-dividing cells during ciliogenesis. The common underlying theme between spindle formation and ciliogenesis is the role of microtubules and microtubule organising centres. Hence, the emerging hypothesis is that all Neks may play a role in the organisation of microtubules. However, for several Neks, little if any information is available. In this thesis, I therefore began to examine the properties of three less well researched human Neks, Nek3, Nek5 and Nek11. First of all, antibodies against each of these kinases were generated or characterised. This allowed a broad study of the localisation, expression and activity of these kinases. Intriguingly, Nek3, Nek5 and Nek11 were all localised to centrosomes. Based on these results a more detailed study was performed with human Nek5 for which there is currently no published data. Human Nek5 is a nuclear protein that localises to the centrosomes during interphase, spindle poles during early mitosis, and to basal bodies in mono- ciliated cells. Specifically, Nek5 localised at the proximal ends of centrioles peaking in intensity in early mitosis. Importantly, siRNA-mediated depletion of Nek5 results in premature centrosome splitting and loss of centrosomal γ-tubulin. Hence, Nek5 is uncovered as a potential player in the negative regulation of centrosome separation.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

“Because it is a rare disease…it needs to be brought to attention that there are things out of the norm”: A qualitative study of patient and physician experiences of Wilson disease diagnosis and management in the US

Abstract Background Wilson disease (WD) is a genetic disorder of copper metabolism that leads to copper accumulation in various organs, primarily the liver and brain, resulting in heterogenous hepatic, neurologic, and psychiatric symptoms. Diagnosis can occur at any age, often leading to lifelong treatment. This qualitative study aims to understand the wider patient and physician experience of the diagnosis and management of WD in the US. Methods Primary data were collected from 1:1 semi structured interviews with US-based patients and physicians and thematically analyzed with NVivo. Results Twelve WD patients and 7 specialist WD physicians (hepatologists and neurologists) were interviewed. Analysis of the interviews revealed 18 themes, which were organized into 5 overarching categories: 1) Diagnosis journey, 2) Multidisciplinary approach, 3) Medication, 4) The role of insurance, and 5) Education, awareness, and support. Patients who presented with psychiatric or neurological symptoms reported longer diagnostic journeys (range 1 to 16 years) than those presenting with hepatic symptoms or through genetic screening (range 2 weeks to 3 years). All were also affected by geographical proximity to WD specialists and access to comprehensive insurance. Exploratory testing was often burdensome for patients, but receipt of a definitive diagnosis led to relief for some. Physicians emphasized the importance of multidisciplinary teams beyond hepatology, neurology, and psychiatry and recommended a combination of chelation, zinc, and a low-copper diet; however, only half the patients in this sample were on a chelator, and some struggled to access prescription zinc due to insurance issues. Caregivers often advocated for and supported adolescents with their medication and dietary regimen. Patients and physicians recommended more education and awareness for the healthcare community. Conclusions WD requires the coordination of care and medication among several specialists due to its complex nature, but many patients do not have access to multiple specialties due to geographical or insurance barriers. Because some patients cannot be treated in Centers of Excellence, easy access to reliable and up-to-date information is important to empower physicians, patients, and their caregivers in managing the condition, along with general community outreach programs.</jats:p

“Because it is a rare disease…it needs to be brought to attention that there are things out of the norm”: a qualitative study of patient and physician experiences of Wilson disease diagnosis and management in the US

Abstract Background Wilson disease (WD) is a genetic disorder of copper metabolism that leads to copper accumulation in various organs, primarily the liver and brain, resulting in heterogenous hepatic, neurologic, and psychiatric symptoms. Diagnosis can occur at any age, requiring lifelong treatment, which can involve liver transplantation. This qualitative study aims to understand the wider patient and physician experience of the diagnosis and management of WD in the US. Methods Primary data were collected from 1:1 semi structured interviews with US-based patients and physicians and thematically analyzed with NVivo. Results Twelve WD patients and 7 specialist WD physicians (hepatologists and neurologists) were interviewed. Analysis of the interviews revealed 18 themes, which were organized into 5 overarching categories: (1) Diagnosis journey, (2) Multidisciplinary approach, (3) Medication, (4) The role of insurance, and (5) Education, awareness, and support. Patients who presented with psychiatric or neurological symptoms reported longer diagnostic journeys (range 1 to 16 years) than those presenting with hepatic symptoms or through genetic screening (range 2 weeks to 3 years). All were also affected by geographical proximity to WD specialists and access to comprehensive insurance. Exploratory testing was often burdensome for patients, but receipt of a definitive diagnosis led to relief for some. Physicians emphasized the importance of multidisciplinary teams beyond hepatology, neurology, and psychiatry and recommended a combination of chelation, zinc, and a low-copper diet; however, only half the patients in this sample were on a chelator, and some struggled to access prescription zinc due to insurance issues. Caregivers often advocated for and supported adolescents with their medication and dietary regimen. Patients and physicians recommended more education and awareness for the healthcare community. Conclusions WD requires the coordination of care and medication among several specialists due to its complex nature, but many patients do not have access to multiple specialties due to geographical or insurance barriers. Because some patients cannot be treated in Centers of Excellence, easy access to reliable and up-to-date information is important to empower physicians, patients, and their caregivers in managing the condition, along with general community outreach programs