NEPA as antiemetic prophylaxis after failure of 5HT3-RA plus dexamethasone in patients receiving carboplatin and gemcitabine chemotherapy: A monocentric real-life experience.

INTRODUCTION: Chemotherapy-induced nausea and vomiting (CINV) may affect adherence to planned chemotherapy treatments and compromise patients' quality of life during the therapy. NEPA is an oral fixed combination of netupitant, a highly-selective NK1-RA and palonosetron, a 5HT3-RA, approved for the prevention of acute and delayed CINV. The aim of this study was to evaluate the efficacy and safety of NEPA with dexamethasone for CINV prophylaxis in the challenging setting of carboplatin and gemcitabine combination chemotherapy, after failure of prophylaxis with 5HT3 receptor antagonist. METHODS: Eligible patients were undergoing carboplatin and gemcitabine combination chemotherapy for metastatic non-small cell lung cancer (NSCLC), ovarian cancer or urothelial cancer and experienced nausea and/or vomiting after the first cycle of chemotherapy, despite an antiemetic prophylaxis with a 5HT3-RA and dexamethasone. Primary efficacy endpoint was complete response (CR: no emesis, no rescue medication) obtained with NEPA, during the overall phase (0-120 h), after the start of chemotherapy. RESULTS: During the first cycle of chemotherapy, 15 out of 30 (50%) patients did not properly control CINV with a 5HT3-RA plus dexamethasone used as primary antiemetic prophylaxis and then were switched to NEPA from the subsequent cycle. During NEPA administration, 13 out of 15 patients (86.7%) achieved an overall CR (no emesis, no rescue medication). Antiemetic treatment with NEPA was very well tolerated with only two patients (13.3%) that experienced a grade 1 TEAE. CONCLUSIONS: Our experience showed that NEPA has proven to be very effective and well tolerated in the prophylaxis of CINV induced by carboplatin-based chemotherapy.

Avoiding alert fatigue in pulmonary embolism decision support: a new method to examine 'trigger rates'.

A clinical decision support system (CDSS) is integrated into the electronic health record (EHR) and allows physicians to easily use a clinical decision support (CDS) tool. However, often CDSSs are integrated into the EHR with poor adoption rates. One reason for this is secondary to 'trigger fatigue'. Therefore, we developed a new and innovative usability process named 'sensitivity and specificity trigger analysis' (SSTA) as part of our larger project around a pulmonary embolism decision support tool. SSTA will enable programmers to examine optimal trigger rates prior to the integration of a CDS tool into the EHR, by using a formal method of analysis. We performed a retrospective chart review. The outcome of interest was physician ordering of a CT angiography (CTA). Phrases that signify common symptoms associated with pulmonary embolism were assessed as possible triggers for the CDSS tool. We then analysed each trigger's ability to predict physician ordering of a CTA. We found that the most sensitive way to trigger the Pulmonary Embolism CDS tool while still maintaining a high specificity was by combining 1 or more pertinent symptoms with 1 or more elements of the Wells criteria. This study explored a unique methodology, SSTA, used to limit inaccurate triggering of a CDS tool prior to integration into the EHR. This methodology can be applied to other studies aiming to decrease triggering rates and increase adoption rates of previously validated CDSS tools.

Formative assessment and design of a complex clinical decision support tool for pulmonary embolism.

Electronic health record (EHR)-based clinical decision support (CDS) tools are rolled out with the urgency to meet federal requirements without time for usability testing and refinement of the user interface. As part of a larger project to design, develop and integrate a pulmonary embolism CDS tool for emergency physicians, we conducted a formative assessment to determine providers' level of interest and input on designs and content. This was a study to conduct a formative assessment of emergency medicine (EM) physicians that included focus groups and key informant interviews. The focus of this study was twofold, to determine the general attitude towards CDS tool integration and the ideal integration point into the clinical workflow. To accomplish this, we first approached EM physicians in a focus group, then, during key informant interviews, we presented workflow designs and gave a scenario to help the providers visualise how the CDS tool works. Participants were asked questions regarding the trigger location, trigger words, integration into their workflow, perceived utility and heuristic of the tool. Results from the participants' survey responses to trigger location, perceived utility and efficiency, indicated that the providers felt the tool would be more of a hindrance than an aid. However, some providers commented that they had not had exposure to CDS tools but had used online calculators, and thought the tools would be helpful at the point-of-care if integrated into the EHR. Furthermore, there was a preference for an order entry wireframe. This study highlights several factors to consider when designing CDS tools: (1) formative assessment of EHR functionality and clinical environment workflow, (2) focus groups and key informative interviews to incorporate providers' perceptions of CDS and workflow integration and/or (3) the demonstration of proposed workflows through wireframes to help providers visualise design concepts.

CT and MR imaging of cystic renal lesions.

Cystic renal lesions are a common incidental finding on routinely imaging examinations. Although a benign simple cyst is usually easy to recognize, the same is not true for complex and multifocal cystic renal lesions, whose differential diagnosis includes both neoplastic and non-neoplastic conditions. In this review, we will show a series of cases in order to provide tips to identify benign cysts and differentiate them from malignant ones.

Improving Provider Adoption With Adaptive Clinical Decision Support Surveillance: An Observational Study.

BACKGROUND: Successful clinical decision support (CDS) tools can help use evidence-based medicine to effectively improve patient outcomes. However, the impact of these tools has been limited by low provider adoption due to overtriggering, leading to alert fatigue. We developed a tracking mechanism for monitoring trigger (percent of total visits for which the tool triggers) and adoption (percent of completed tools) rates of a complex CDS tool based on the Wells criteria for pulmonary embolism (PE). OBJECTIVE: We aimed to monitor and evaluate the adoption and trigger rates of the tool and assess whether ongoing tool modifications would improve adoption rates. METHODS: As part of a larger clinical trial, a CDS tool was developed using the Wells criteria to calculate pretest probability for PE at 2 tertiary centers' emergency departments (EDs). The tool had multiple triggers: any order for D-dimer, computed tomography (CT) of the chest with intravenous contrast, CT pulmonary angiography (CTPA), ventilation-perfusion scan, or lower extremity Doppler ultrasound. A tracking dashboard was developed using Tableau to monitor real-time trigger and adoption rates. Based on initial low provider adoption rates of the tool, we conducted small focus groups with key ED providers to elicit barriers to tool use. We identified overtriggering of the tool for non-PE-related evaluations and inability to order CT testing for intermediate-risk patients. Thus, the tool was modified to allow CT testing for the intermediate-risk group and not to trigger for CT chest with intravenous contrast orders. A dialogue box, "Are you considering PE for this patient?" was added before the tool triggered to account for CTPAs ordered for aortic dissection evaluation. RESULTS: In the ED of tertiary center 1, 95,295 patients visited during the academic year. The tool triggered for an average of 509 patients per month (average trigger rate 2036/30,234, 6.73%) before the modifications, reducing to 423 patients per month (average trigger rate 1629/31,361, 5.22%). In the ED of tertiary center 2, 88,956 patients visited during the academic year, with the tool triggering for about 473 patients per month (average trigger rate 1892/29,706, 6.37%) before the modifications and for about 400 per month (average trigger rate 1534/30,006, 5.12%) afterward. The modifications resulted in a significant 4.5- and 3-fold increase in provider adoption rates in tertiary centers 1 and 2, respectively. The modifications increased the average monthly adoption rate from 23.20/360 (6.5%) tools to 81.60/280.20 (29.3%) tools and 46.60/318.80 (14.7%) tools to 111.20/263.40 (42.6%) tools in centers 1 and 2, respectively. CONCLUSIONS: Close postimplementation monitoring of CDS tools may help improve provider adoption. Adaptive modifications based on user feedback may increase targeted CDS with lower trigger rates, reducing alert fatigue and increasing provider adoption. Iterative improvements and a postimplementation monitoring dashboard can significantly improve adoption rates.

Communicating with the hepatobiliary surgeon through structured report.

Communicating radiological findings to hepatobiliary surgeons is not an easy task due to the complexity of liver imaging, coexistence of multiple hepatic lesions and different surgical treatment options. Recently, the adoption and implementation of structured report in everyday clinical practice has been supported to achieve higher quality, more reproducibility in communication and closer adherence to current guidelines. In this review article, we will illustrate the main benefits, strengths and limitations of structured reporting, with particular attention on the advantages and challenges of structured template in the preoperative evaluation of cirrhotic and non-cirrhotic patients with focal liver lesions. Structured reporting may improve the preoperative evaluation, focusing on answering specific clinical questions that are requested by hepatobiliary surgeons in candidates to liver resection.

Role of Imaging in the Assessment of Age Estimation.

Age assessment by skeletal age estimation of unknown individuals is of paramount importance in forensic science, both for assessing imputability (if the author of a crime is old enough to be tried and judged), both in case of unaccompanied minors, or whether refugees and asylum seekers are adults or juveniles, which implies different legal issues and procedures. The aim of this article is to review the age estimation methods used in forensic practice.

Imaging features of adrenal masses.

The widespread use of imaging examinations has increased the detection of incidental adrenal lesions, which are mostly benign and non-functioning adenomas. The differentiation of a benign from a malignant adrenal mass can be crucial especially in oncology patients since it would greatly affect treatment and prognosis. In this setting, imaging plays a key role in the detection and characterization of adrenal lesions, with several imaging tools which can be employed by radiologists. A thorough knowledge of the imaging features of adrenal masses is essential to better characterize these lesions, avoiding a misinterpretation of imaging findings, which frequently overlap between benign and malignant conditions, thus helping clinicians and surgeons in the management of patients. The purpose of this paper is to provide an overview of the main imaging features of adrenal masses and tumor-like conditions recalling the strengths and weaknesses of imaging modalities commonly used in adrenal imaging.

Usability Testing of a Complex Clinical Decision Support Tool in the Emergency Department: Lessons Learned.

BACKGROUND: As the electronic health record (EHR) becomes the preferred documentation tool across medical practices, health care organizations are pushing for clinical decision support systems (CDSS) to help bring clinical decision support (CDS) tools to the forefront of patient-physician interactions. A CDSS is integrated into the EHR and allows physicians to easily utilize CDS tools. However, often CDSS are integrated into the EHR without an initial phase of usability testing, resulting in poor adoption rates. Usability testing is important because it evaluates a CDSS by testing it on actual users. This paper outlines the usability phase of a study, which will test the impact of integration of the Wells CDSS for pulmonary embolism (PE) diagnosis into a large urban emergency department, where workflow is often chaotic and high stakes decisions are frequently made. We hypothesize that conducting usability testing prior to integration of the Wells score into an emergency room EHR will result in increased adoption rates by physicians. OBJECTIVE: The objective of the study was to conduct usability testing for the integration of the Wells clinical prediction rule into a tertiary care center's emergency department EHR. METHODS: We conducted usability testing of a CDS tool in the emergency department EHR. The CDS tool consisted of the Wells rule for PE in the form of a calculator and was triggered off computed tomography (CT) orders or patients' chief complaint. The study was conducted at a tertiary hospital in Queens, New York. There were seven residents that were recruited and participated in two phases of usability testing. The usability testing employed a "think aloud" method and "near-live" clinical simulation, where care providers interacted with standardized patients enacting a clinical scenario. Both phases were audiotaped, video-taped, and had screen-capture software activated for onscreen recordings. RESULTS: Phase I: Data from the "think-aloud" phase of the study showed an overall positive outlook on the Wells tool in assessing a patient for a PE diagnosis. Subjects described the tool as "well-organized" and "better than clinical judgment". Changes were made to improve tool placement into the EHR to make it optimal for decision-making, auto-populating boxes, and minimizing click fatigue. Phase II: After incorporating the changes noted in Phase 1, the participants noted tool improvements. There was less toggling between screens, they had all the clinical information required to complete the tool, and were able to complete the patient visit efficiently. However, an optimal location for triggering the tool remained controversial. CONCLUSIONS: This study successfully combined "think-aloud" protocol analysis with "near-live" clinical simulations in a usability evaluation of a CDS tool that will be implemented into the emergency room environment. Both methods proved useful in the assessment of the CDS tool and allowed us to refine tool usability and workflow.

[Radiofrequency thermoablation in the treatment of primary and secondary liver tumours]. / La termoablazione nel trattamento delle neoplasie epatiche primitive e secondarie.

Radiofrequency thermoablation is a locoregional procedure based on the use of electromagnetic waves that induce movement and consequently the production of heat. This is the basis for the coagulative necrosis produced in the tissues. The method, experimented with and developed in the '90s, is today extensively used in the treatment of focal hepatic lesions, both primary and secondary. The factors that condition the procedure are related essentially to the characteristics of the tumours and to the possibility of obtaining a predictable area of necrosis that guarantees the radicality of the treatment. As regards primary neoplasms, it should be stressed that the treatment for hepatocellular carcinoma is implemented only in a small percentage of cases due to both the stage of the cirrhosis and because a wide resection is not justified for small-sized lesions or for recurrences after resection. As far as liver metastases are concerned, particularly those from the colon-rectum, surgery is becoming increasingly indicated. Obviously the conditions are decidedly less demanding than those of surgery in liver parenchyma with cirrhosis. Radiofrequency thermal ablation, even in this condition, has a place as an alternative or in combination with liver resection, particularly during recurrences or in cases of multiple metastases that require extensive extirpative operations. The authors present their experience over the period from February 1999 to December 2002 in 82 patients, 71 with hepatocellular carcinoma and 11 with metastases, treated with radiofrequency thermoablation. Depending upon the site, the number of lesions and the Child-Pugh functional classes in patients with cirrhosis, 117 treatments were carried out: the percutaneous approach was used in 77 cases and the open procedure in 36, while the thermoablation was combined with surgical resection in 4 cases. The results are examined on the basis of perioperative morbidity and mortality and local recurrence, and the time of hospitalisation is compared in the different patient groups. The authors conclude favourably for this procedure, which is associated with an extremely low percentage of complications and with an almost total lack of perioperative mortality, and in some cases may be a valid alternative and in other cases a useful complement to resection treatment.

Treatment of hepatocellular carcinoma in compensated cirrhosis with radio-frequency thermal ablation (RFTA): a prospective study.

BACKGROUND/AIMS: To assess the effectiveness and the safety of radio-frequency thermal ablation (RFTA) in patients with hepatocellular carcinoma (HCC) < or = 5 cm in compensated cirrhosis. METHODS: A cohort of 202 consecutive patients (165 Child-Pugh class A and 37 class B) was prospectively assessed. A single lesion was observed in 160/202 (79.2%), two lesions in 29/202 (14.3%), and three lesions in 13/202 (6.4%) of patients. RESULTS: Sixty-seven patients died. Survival rates were 80% at 12 months, 67% at 24 months and 57% at 30 months (Child-Pugh A 59% and Child-Pugh B 48%). By Cox regression analysis, survival was independently predicted by serum albumin levels > or = 35 g/L, platelet count > or = 100.000/mmc, tumor size < or = 3 cm, complete response at 1 month and Barcelona Clinic Liver Cancer (BCLC) staging classification. Overall recurrence rates were 22, 38, and 44% at 12, 24, and 30 months, respectively. One procedure-related death occurred. The proportion of major complications after treatment was 3.9%. CONCLUSIONS: A complete response after RFTA significantly increases survival. The longest survival is obtained in the presence of HCC < or = 3 cm and of higher baseline albumin levels and platelet counts. BCLC staging classification is able to discriminate patients with good or poor prognosis.