The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. METHODS: The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. RESULTS: The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. CONCLUSION: These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.

IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias.

OBJECTIVE: To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. BACKGROUND: Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. METHODS: Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. RESULTS: Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. CONCLUSIONS: PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.

Fabrication of a disposable aptasensing chip for simultaneous label-free detection of four common coexisting mycotoxins.

BACKGROUND: Coexisting multiple mycotoxins in food poses severe health risks on humans due to the augmented toxicity. Current multiplex detection methods for mycotoxins have evolved from instrumental analyses to rapid methods based on the specific recognition of antibody/aptamer using different signal transducers. However, nearly all of the reported aptasensors for multiple mycotoxins detection require external labels and can only simultaneous detection of two mycotoxins due to the limitation of distinguishable labels. The tedious labeling process definitely increases the operation complexity and the detection cost. Therefore, rapid method for simultaneous label-free detection of multiple mycotoxins in cereals is urgently needed. RESULTS: A disposable aptasensing chip was designed for simultaneous label-free detection of fumonisin B1 (FB1), aflatoxin B1 (AFB1), zearalenone (ZEN), and ochratoxin A (OTA) in one sample. Specifically, ITO conductive glass was divided into a rectangle (35 × 25 mm) and then etched by laser to set aside the required four ITO working electrodes (6 mm in diameter) with respective conductive channels. Gold nanoparticles were electrodeposited on the working electrodes to provide abundant anchoring sites for thiolated aptamers immobilization. On this basis, a disposable aptasensing chip for simultaneous label-free detection of four common coexisting mycotoxins has been developed, which used electrochemical impedance spectroscopy as transducer to measure direct biorecognition of the aptamer and corresponding target. This aptasensing chip provided wide linear ranges of 5-1000, 10-250, 10-1250, 10-1500 ng/mL for FB1, AFB1, ZEN, OTA, respectively, with the respective detection limit of 2.47, 3.19, 5.38, 4.87 ng/mL (S/N = 3). SIGNIFICANCE AND NOVELTY: This aptasensing chip shows fantastic characteristics of great simplicity and portability, easy operation, and multiple mycotoxins recognition. They are easy to produce on a large scale at low cost and the design concept can be easily expanded to screen a large panel of coexisting targets. This work provides a new avenue for multi-target detection and represents a substantial advance toward food quality and safety monitoring or other fields.

Tailoring of neurosurgical practice during COVID-19 in a developing country: Insights gained and a way forward.

Background: The coronavirus disease-19 pandemic has aggravated the already neglected neurosurgical specialty in developing countries with a mounting shortage of specialists, long queues of operative patients, and a lack of adequate critical care units. Methods: We have reviewed the innovative strategies adopted for maintaining an optimal surgical practice while ensuring team safety at the Aga Khan University Hospital, Karachi Pakistan. Results: There is already a scarcity of resources in developing countries. The international guidelines had to be tailored to the context of the developing world. A multimodal strategy that focused on infection control, continuum of care, and the well-being of staff was adopted at Aga Khan University. Patients were screened and seen either in person or through telemedicine, depending on the severity of the disease. All educational activities for residents were shifted online, and this helped in preventing overcrowding. Conclusion: Optimal surgical practice while ensuring team safety can be achieved through a multimodal strategy focusing on infection control, continuum of care, and the well-being of staff.

Supervised weight loss requirements disproportionately affect Black patients seeking weight loss surgery.

BACKGROUND: We use our high-volume institutional experience with a majority Black population to examine the role of supervised weight loss (SWL) requirements perpetuating disparities in bariatric surgery. OBJECTIVE: To determine if there are racial disparities in the required amount of supervised weight loss prior to approval for bariatric surgery. SETTING: University hospital. METHODS: A retrospective review was conducted of all patients seen at our institution's bariatric surgery clinic in 2018. Odds of undergoing surgery within 1 year and mean number of SWL requirements were determined using descriptive statistics for Black patients as compared with non-Hispanic White patients. Finally, a logistic model was constructed to examine likelihood of undergoing an operation within 1 year for patients of varying SWL requirements. RESULTS: A total of 335 patients were included (75% Black, 25% White). Within 1 year, 37% of Black patients compared with 53% of White patients had undergone an operation (relative risk .7, P = .01). Mean insurance-mandated SWL sessions were significantly higher for Black patients (3.6 ± 2.8) versus non-Hispanic White patients (2.2 ± 2.7) (P < .01). Mean program-mandated SWL sessions were also significantly higher for Black patients (2.5 ± 2.6) versus non-Hispanic White patients (.8 ± 1.8) (P < .01). Increasing SWL requirements significantly reduced the odds of undergoing surgery at 1 year within the entire cohort (odds ratio .86, P < .01). CONCLUSIONS: Black patients are disproportionally affected by SWL requirements, which strongly correlate with decreased likelihood of undergoing a bariatric operation as compared with their White counterparts. Even after overcoming barriers to see a bariatric surgery provider, Black patients still face disproportionally more barriers to surgery. Bariatric centers must be sensitive to the effect of SWL requirements, as it is negatively associated with the likelihood of a patient receiving a bariatric operation.

The quality of life among Sudanese patients with epilepsy, Khartoum, Sudan.

INTRODUCTION: This is the first study done in the National Center for Neurological Sciences, Khartoum State, to assess the quality of life among more than 100 Sudanese epileptic patients, in the period from September to December 2020. METHODOLOGY: This is a descriptive cross-sectional study; data were collected using an interview-based semi-structured structured questionnaire and this questionnaire was modified from the SF-36 model. RESULTS: Most of the patients were from urban areas and origin (60.2%), most of which were housewives; the majority of the patients were single and from low socioeconomic status, history of the disease was less than 3 years for most of the cases covered in this study, most of the cases were classified as generalized tonic clonic epilepsy, and normal EEG findings and normal MRI brain were found in 75.7% and 78.6%, respectively. Most patients mentioned that they experienced no attacks during the last month. Regarding mental health, 47.6% experienced symptoms of depression, and 75.7% had memory problems. In terms of physical health, 51.5% felt energetic all of the time, 9.7% experienced remarkable sleep disturbance, most of the patients are not driving nor have established hobbies during leisure time. 63.1% of the participants do not have health problems; 32% mentioned that they would feel stigmatized if an attack takes place in public. Commonest medication prescribed was carbamazepine, out of which 73.8% are fully compliant with their medication. 95.1% are not worried about long term use of medication. CONCLUSION: Lower levels of education and manual labor are associated with poor quality of life. Epilepsy has an adverse impact on social life. There is a global decrease in cognitive function, and most of the patients are not worried about the side effects and duration of the medication usage.

First American College of Surgeons National Surgical Quality Improvement Program Report from a Low-Middle-Income Country: A 1-Year Outcome Analysis of Neurosurgical Cases.

BACKGROUND: Low-middle-income countries (LMICs) share a substantial proportion of global surgical complications. This is compounded by the seemingly deficient documentation of postsurgical complications and the lack of a national average for comparison. In this context, the implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) that compares hospital performance based on postsurgical complication data provided by a wide array of centers, could be a major initiative in a resource-challenged setting. Implementation of the NSQIP has provenly mitigated postoperative morbidity and mortality across many centers all over the world. To our knowledge, this report is the first from an LMIC to report its postoperative neurosurgical complications in comparison with international benchmarks. METHODS: Our hospital joined the NSQIP in 2019. Through a standardized ACS protocol, ACS-trained surgical clinical reviewers (SCRs) reviewed and extracted data from randomly assigned neurosurgical patients' medical records from preoperative to postoperative (30-day) data using validated, standardized data definitions. SCRs entered deidentified data in an online Health Insurance Portability and Accountability Act web-based secure platform. The validated data were then consigned to the ACS NSQIP head office in the United States where the data were analyzed and compared with similar data from other centers registered with the NSQIP. In this way, our hospital was rated for each of the variables related to postsurgical complications after both spinal and cranial procedures, and the results were sent back to us in the form of text, tables, and graphs. RESULTS: Our initial report suggested a relatively higher odds ratio for sepsis and readmissions after spinal procedures at our hospital, and a similarly higher odds ratio for morbidity, sepsis, urinary tract infection, and surgical site infection for cranial procedures. For these variables, our hospital fell in the needs improvement category of the NSQIP. For the rest of the variables studied for both spinal and cranial procedures, the hospital fell in the as expected category of the NSQIP. CONCLUSIONS: Implementation of the NSQIP is an important first step in creating a culture of transparency, safety, and quality. This is the first report of NSQIP implementation in an LMIC, and we have shown comparable results to developed countries.

Are Thinking Machines Breaking New Frontiers in Neuro-Oncology? A Narrative Review on the Emerging Role of Machine Learning in Neuro-Oncological Practice.

Medical science in general and oncology in particular are dynamic, rapidly evolving subjects. Brain and spine tumors, whether primary or secondary, constitute a significant number of cases in any oncological practice. With the rapid influx of data in all aspects of neuro-oncological care, it is almost impossible for practicing clinicians to remain abreast with the current trends, or to synthesize the available data for it to be maximally beneficial for their patients. Machine-learning (ML) tools are fast gaining acceptance as an alternative to conventional reliance on online data. ML uses artificial intelligence to provide a computer algorithm-based information to clinicians. Different ML models have been proposed in the literature with a variable degree of precision and database requirements. ML can potentially solve the aforementioned problems for practicing clinicians by not just extracting and analyzing useful data, by minimizing or eliminating certain potential areas of human error, by creating patient-specific treatment plans, and also by predicting outcomes with reasonable accuracy. Current information on ML in neuro-oncology is scattered, and this literature review is an attempt to consolidate it and provide recent updates.

Open science, COVID-19, and the news: Exploring controversies in the circulation of early SARS-CoV-2 genomic epidemiology research.

Some early English language news coverage of COVID-19 epidemiology focused on studies that examined how SARS-CoV-2 (the coronavirus that causes COVID-19) was evolving at the genetic level. The use of phylogenetic methods to analyse pathogen genetic sequence data to understand disease dynamics is called 'molecular' or 'genomic' epidemiology. Many research groups in this subfield utilise open science practices, which can involve the circulation of early unreviewed findings on publicly-accessible venues online. From March to May 2020, media outlets covered early SARS-CoV-2 genomic studies that claimed to have discovered types of SARS-CoV-2 that had mutated to be more transmissible. We use methods from Science and Technology Studies (STS) to examine three cumulative cases in which unripe facts about SARS-CoV-2 genomics moved out of scientific publics and into mainstream news. The three cases are: (1) 'A More "Aggressive" Strain of SARS-CoV-2?', (2) 'Eight SARS-CoV-2 Strains?', and (3) 'A "More Contagious," "Mutant" Strain?' In each case, findings were called into question and reporters' framing was overly sensational. We interpret the COVID-19 pandemic as a 'stress-test' for open science practices, and argue that it is important for stakeholders to understand changes in scientific publication and dissemination processes in the wake of the pandemic.

Alternatives to sharing COVID-19 data with law enforcement: Recommendations for stakeholders.

During the COVID-19 pandemic, in some jurisdictions, police have become involved in enforcing coronavirus-related measures. Relatedly, several North American jurisdictions have established COVID-19 data sharing protocols with law enforcement. Research across a range of fields has demonstrated that involving police in matters of public health disproportionately impacts the most vulnerable and does more harm than good. This is reflected in the consensus against COVID-19 criminalization that has emerged among civil society organizations focused on HIV, human rights, and harm reduction. The European Data Protection Board has also released guidelines against re-uses of COVID-19 data for law enforcement purposes. This article offers an overview of the harms of criminalizing illnesses and strategies for health stakeholders to seek alternatives to sharing COVID-19 data with police agencies while facilitating interoperability with healthcare first responders. It also presents case studies from two North American jurisdictions - Ontario and Minnesota - that have established routine COVID-19 data sharing with police. We recommended seven alternatives, including designating COVID-19 data as sensitive and implementing segmented interoperability with first responder agencies. These guidelines can help ensure that health information technology platforms do not become vehicles for the criminalization of COVID-19, and that health data stay within the health system.

Phenotyping as disciplinary practice: data infrastructure and the interprofessional conflict over drug use in California.

The narrative of the digital phenotype as a transformative vector in healthcare is nearly identical to the concept of "data drivenness" in other fields such as law enforcement. We examine the role of a prescription drug monitoring program (PDMP) in California-a computerized law enforcement surveillance program enabled by a landmark Supreme Court case that upheld "broad police powers"-in the interprofessional conflict between physicians and law enforcement over the jurisdiction of drug use. We bring together interview passages, clinical artifacts, and academic and gray literature to investigate the power relations between police, physicians, and patients to show that prescribing data appear to the physician as evidence of problematic patient behavior by the patients, and to law enforcement as evidence of physician misconduct. In turn, physicians have adopted a disciplinary approach to patients, using quasi-legalistic documents to litigate patient behavior. We conclude that police powers have been used to pave data infrastructure through a contested jurisdiction, and law enforcement have used that infrastructure to enroll physicians into the work of disciplining patients.

Role of Social Media Marketing Activities in Influencing Customer Intentions: A Perspective of a New Emerging Era.

The aim of this study is to explore social media marketing activities (SMMAs) and their impact on consumer intentions (continuance, participate, and purchase). This study also analyzes the mediating roles of social identification and satisfaction. The participants in this study were experienced users of two social media platforms Facebook and Instagram in Pakistan. A self-administered questionnaire was used to collect data from respondents. We used an online community to invite Facebook and Instagram users to complete the questionnaire in the designated online questionnaire system. Data were collected from 353 respondents, and structural equation modeling (SEM) was used to analyze the data. Results show that SMMAs have a significant impact on the intentions of users. Furthermore, social identification mediates the relationship between social media activities and satisfaction, and satisfaction mediates the relationship between social media activities and the intentions of users. This will help marketers how to attract customers to develop their intentions. This is the first novel study that used SMMAs to address the user intentions with the role of social identification and satisfaction in the context of Pakistan.

Creation of a COVID-19 Based Educational Curriculum: A Blueprint for Redesigning Surgical Education During Times of National Crisis.

Objective: To create a COVID-19 based educational curriculum for surgical residents. Background Data: The COVID-19 pandemic has resulted in disruptions to operative volume and clinical education for surgery residents. This has placed a greater importance on didactic education. However, in the face of pandemic-related uncertainty, focusing on a traditional educational curriculum may be a challenge for surgical residents. Methods: A dedicated resident educational team was created. This team identified specific surgical resident needs, evaluated institutional resources, created a curriculum and timeline, determined a feasible implementation format, and assessed resident opinions on the impact of the curriculum via anonymous survey. Results: A 1-month long COVID-19 based curriculum was developed, which covered (1) advanced critical care and resuscitation techniques pertinent to patients with COVID-19, (2) institutional physician experience in the COVID-units, (3) ethical dilemmas in resource management, (4) triaging of operative cases during the pandemic, and (5) published and ongoing COVID-19-related surgical research. In the postimplementation survey, a majority of residents reported that the curriculum helped improve their ability to take care of patients during the pandemic, provided an opportunity for questions, alleviated anxieties and concerns, and that they preferred the COVID-19 curriculum over traditional surgical topics. Conclusions: In the midst of national crisis and significant clinical disruption, real-time adjustments to surgical education can and should occur to address resident needs. The results of our study may serve as a blueprint for implementing rapid change to resident education in the future.

A scoping review of qualitative research in JAMIA: past contributions and opportunities for future work.

OBJECTIVE: Qualitative methods are particularly well-suited to studying the complexities and contingencies that emerge in the development, preparation, and implementation of technological interventions in real-world clinical practice, and much remains to be done to use these methods to their full advantage. We aimed to analyze how qualitative methods have been used in health informatics research, focusing on objectives, populations studied, data collection, analysis methods, and fields of analytical origin. METHODS: We conducted a scoping review of original, qualitative empirical research in JAMIA from its inception in 1994 to 2019. We queried PubMed to identify relevant articles, ultimately including and extracting data from 158 articles. RESULTS: The proportion of qualitative studies increased over time, constituting 4.2% of articles published in JAMIA overall. Studies overwhelmingly used interviews, observations, grounded theory, and thematic analysis. These articles used qualitative methods to analyze health informatics systems before, after, and separate from deployment. Providers have typically been the main focus of studies, but there has been an upward trend of articles focusing on healthcare consumers. DISCUSSION: While there has been a rich tradition of qualitative inquiry in JAMIA, its scope has been limited when compared with the range of qualitative methods used in other technology-oriented fields, such as human-computer interaction, computer-supported cooperative work, and science and technology studies. CONCLUSION: We recommend increased public funding for and adoption of a broader variety of qualitative methods by scholars, practitioners, and policy makers and an expansion of the variety of participants studied. This should lead to systems that are more responsive to practical needs, improving usability, safety, and outcomes.

Determination of linear alkylbenzenes (LABs) in mangrove ecosystems using the oyster Crassostrea belcheri as a biosensor.

The current study aimed to develop a suitable molecular marker [Linear alkylbenzenes (LABs)] approach for pollution determination in mangrove oysters of peninsular Malaysia. C. belcheri species were collected from rivers of Merbok, Perai, Klang, Muar and PulauMerambong (An Island). The LABs were extracted from C. belcheri and determined using GC-MS. The LABs indices which included I/E, L/S and C13/C12 were applied to describe the sources and biodegradation of LABs. The results revealed that the maximum concentrations were detected in oysters from Klang (27.91 ng g-1dw), while the lowest concentrations were detected in oysters from Merbok (8.12 ng g-1dw). Moreover, I/E ratios varied between 2.83 and 6.40, indicating the secondary treatment effluents being discharged to coastal zones. The results of this study suggested that the oysters absorbed LABs mainly in dissolved phase. Therefore, mangrove oysters are a good biosensor for LABs contamination in the aquatic environment.

What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate?

INTRODUCTION: Among surgeons worldwide, a concern with the use of minimally invasive techniques has been raised due to a proposed risk of viral transmission of the coronavirus disease of 2019 (COVID-19) with the creation of pneumoperitoneum. Due to this proposed concern, we sought to collect the available data and evaluate the use of laparoscopy and the risk of COVID-19 transmission. METHODS: A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. RESULTS: Few studies have been performed on viral transmission during surgery, but to date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open or laparoscopic. There is no societal consensus on limiting or restricting laparoscopic or robotic surgery; however, there is expert consensus on the modification of standard practices to minimize any risk of transmission. CONCLUSIONS: Despite very little evidence to support viral transmission through laparoscopic or open approaches, we recommend making modifications to surgical practice such as the use of smoke evacuation and minimizing energy device use among other measures to minimize operative staff exposure to aerosolized particles.

How the presentation of patient information and decision-support advisories influences opioid prescribing behavior: A simulation study.

OBJECTIVE: The United States faces an opioid crisis. Integrating prescription drug monitoring programs into electronic health records offers promise to improve opioid prescribing practices. This study aimed to evaluate 2 different user interface designs for prescription drug monitoring program and electronic health record integration. MATERIALS AND METHODS: Twenty-four resident physicians participated in a randomized controlled experiment using 4 simulated patient cases. In the conventional condition, prescription opioid histories were presented in tabular format, and computerized clinical decision support (CDS) was provided via interruptive modal dialogs (ie, pop-ups). The alternative condition featured a graphical opioid history, a cue to visit that history, and noninterruptive CDS. Two attending pain specialists judged prescription appropriateness. RESULTS: Participants in the alternative condition wrote more appropriate prescriptions. When asked after the experiment, most participants stated that they preferred the alternative design to the conventional design. CONCLUSIONS: How patient information and CDS are presented appears to have a significant influence on opioid prescribing behavior.

Frequent inappropriate use of unweighted summary statistics in systematic reviews of pathogen genotypes or genogroups.

OBJECTIVES: Our study aimed to systematically assess and report the methodological quality used in epidemiological systematic reviews (SRs) and meta-analysis (MA) of pathogen genotypes/genogroups. STUDY DESIGN AND SETTING: Nine electronic databases and manual search of reference lists were used to identify relevant studies. The method types were divided into three groups: 1) with weighted pooling analysis (which we call MA), (2) unweighted analysis of the study-level measures (which we call summary statistics), and (3) without any data pooling (which we call SR only). Characteristics were evaluated using Assessment of Multiple Systematic Reviews (AMSTAR), Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Risk Of Bias In Systematic reviews (ROBIS) tools. The protocol was registered in PROSPERO with CRD42017078146. RESULTS: Among 36 included articles, 5 (14%) studies conducted SR only, 16 (44%) performed MA, and 15 (42%) used summary statistics. The univariable and multivariable linear regression of AMSTAR and PRISMA scores showed that MA had higher quality compared with those with summary statistics. The SR only and summary statistics groups had approximately equal scores among three scales of AMSTAR, PRISMA, and ROBIS. The methodological quality of epidemiological studies has improved from 1999 to 2017. CONCLUSION: Despite the frequent use of unweighted summary statistics, MA remains the most suitable method for reaching rational conclusions in epidemiological studies of pathogen genotypes/genogroups.

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review.

OBJECTIVE: Alert fatigue limits the effectiveness of medication safety alerts, a type of computerized clinical decision support (CDS). Researchers have suggested alternative interactive designs, as well as tailoring alerts to clinical roles. As examples, alerts may be tiered to convey risk, and certain alerts may be sent to pharmacists. We aimed to evaluate which variants elicit less alert fatigue. MATERIALS AND METHODS: We searched for articles published between 2007 and 2017 using the PubMed, Embase, CINAHL, and Cochrane databases. We included articles documenting peer-reviewed empirical research that described the interactive design of a CDS system, to which clinical role it was presented, and how often prescribers accepted the resultant advice. Next, we compared the acceptance rates of conventional CDS-presenting prescribers with interruptive modal dialogs (ie, "pop-ups")-with alternative designs, such as role-tailored alerts. RESULTS: Of 1011 articles returned by the search, we included 39. We found different methods for measuring acceptance rates; these produced incomparable results. The most common type of CDS-in which modals interrupted prescribers-was accepted the least often. Tiering by risk, providing shortcuts for common corrections, requiring a reason to override, and tailoring CDS to match the roles of pharmacists and prescribers were the most common alternatives. Only 1 alternative appeared to increase prescriber acceptance: role tailoring. Possible reasons include the importance of etiquette in delivering advice, the cognitive benefits of delegation, and the difficulties of computing "relevance." CONCLUSIONS: Alert fatigue may be mitigated by redesigning the interactive behavior of CDS and tailoring CDS to clinical roles. Further research is needed to develop alternative designs, and to standardize measurement methods to enable meta-analyses.

Exposure to violence and its association with symptoms of aggression: A cross sectional study among medical students of Karachi, Pakistan.

OBJECTIVE: To explore the experience of violence and its association with symptoms of aggression among medical students. METHODS: The cross-sectional study was conducted from January 5 to 14, 2018, at Dow University of Health Sciences, Karachi, and comprised medical students who were interviewed using a self-reporting questionnaire that had three sections: demographics, the Aggression Questionnaire, and the Exposure to Violence Scale. Data were analysed using SPSS 20.. RESULTS: Of the 192 subjects, 144(75%) were females and 48(25%) were males, with an overall mean age of 21.39+/- 2 years. Total exposure to violence was significantly higher among older male respondents (p<0.05). It was significantly associated with higher severity of physical aggression and hostility (p<0.05). However, it had no significant relationship with verbal aggression and anger (p>0.05).. CONCLUSIONS: A large proportion of medical students reported exposure to violent events, which was also associated with increased aggression among them.