Evaluation of a Musculoskeletal Digital Assessment Routing Tool (DART): Crossover Noninferiority Randomized Pilot Trial.

BACKGROUND: Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on patients and increasing demand for health care use. Triage directing patients to appropriate level intervention improving health outcomes and efficiency has been prioritized. We developed a musculoskeletal digital assessment routing tool (DART) mobile health (mHealth) system, which requires evaluation prior to implementation. Such innovations are rarely rigorously tested in clinical trials-considered the gold standard for evaluating safety and efficacy. This pilot study is a precursor to a trial assessing DART performance with a physiotherapist-led triage assessment. OBJECTIVE: The study aims to evaluate trial design, assess procedures, and collect exploratory data to establish the feasibility of delivering an adequately powered, definitive randomized trial, assessing DART safety and efficacy in an NHS primary care setting. METHODS: A crossover, noninferiority pilot trial using an integrated knowledge translation approach within a National Health Service England primary care setting. Participants were patients seeking assessment for a musculoskeletal condition, completing a DART assessment and the history-taking element of a face-to-face physiotherapist-led triage in a randomized order. The primary outcome was agreement between DART and physiotherapist triage recommendation. Data allowed analysis of participant recruitment and retention, randomization, blinding, study burden, and potential barriers to intervention delivery. Participant satisfaction was measured using the System Usability Scale. RESULTS: Over 8 weeks, 129 patients were invited to participate. Of these, 92% (119/129) proceeded to eligibility assessment, with 60% (78/129) meeting the inclusion criteria and being randomized into each intervention arm (39/39). There were no dropouts and data were analyzed for all 78 participants. Agreement between physiotherapist and DART across all participants and all primary triage outcomes was 41% (32/78; 95% CI 22-45), intraclass correlation coefficient 0.37 (95% CI 0.16-0.55), indicating that the reliability of DART was poor to moderate. Feedback from the clinical service team led to an adjusted analysis yielding of 78% (61/78; 95% CI 47-78) and an intraclass correlation coefficient of 0.57 (95% CI 0.40-0.70). Participant satisfaction was measured quantitively using amalgamated System Usability Scale scores (n=78; mean score 84.0; 90% CI +2.94 to -2.94), equating to an "excellent" system. There were no study incidents, and the trial burden was acceptable. CONCLUSIONS: Physiotherapist-DART agreement of 78%, with no adverse triage decisions and high patient satisfaction, was sufficient to conclude DART had the potential to improve the musculoskeletal pathway. Study validity was enhanced by the recruitment of real-world patients and using an integrated knowledge translation approach. Completion of a context-specific consensus process is recommended to provide definitive definitions of safety criteria, range of appropriateness, noninferiority margin, and sample size. This pilot demonstrated an adequately powered definitive trial is feasible, which would provide evidence of DART safety and efficacy, ultimately informing potential for DART implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/31541.

Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome.

Background: Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality. Methods: Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019-2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality. Results: Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC. Conclusion: Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted. Level of evidence: Level III-Retrospective study with up to two negative criteria. Study type: Original research; diagnostic accuracy study.

Updating and recalibrating causal probabilistic models on a new target population.

OBJECTIVE: Very often the performance of a Bayesian Network (BN) is affected when applied to a new target population. This is mainly because of differences in population characteristics. External validation of the model performance on different populations is a standard approach to test model's generalisability. However, a good predictive performance is not enough to show that the model represents the unique population characteristics and can be adopted in the new environment. METHODS: In this paper, we present a methodology for updating and recalibrating developed BN models - both their structure and parameters - to better account for the characteristics of the target population. Attention has been given on incorporating expert knowledge and recalibrating latent variables, which are usually omitted from data-driven models. RESULTS: The method is successfully applied to a clinical case study about the prediction of trauma-induced coagulopathy, where a BN has already been developed for civilian trauma patients and now it is recalibrated on combat casualties. CONCLUSION: The methodology proposed in this study is important for developing credible models that can demonstrate a good predictive performance when applied to a target population. Another advantage of the proposed methodology is that it is not limited to data-driven techniques and shows how expert knowledge can also be used when updating and recalibrating the model.

Attitudes towards technology supported rheumatoid arthritis care: investigating patient- and clinician-perceived opportunities and barriers.

Objectives: Globally, demand outstrips capacity in rheumatology services, making Mobile Health (mHealth) attractive, with the potential to improve access, empower patient self-management and save costs. Existing mHealth interventions have poor uptake by end users. This study was designed to understand existing challenges, opportunities and barriers for computer technology in the RA care pathway. Methods: People with RA were recruited from Barts Health NHS Trust rheumatology clinics to complete paper questionnaires and clinicians were recruited from a variety of centres in the UK to complete an online questionnaire. Data collected included demographics, current technology use, challenges managing RA, RA medications and monitoring, clinic appointments, opportunities for technology and barriers to technology. Results: A total of 109 patient and 41 clinician questionnaires were completed. A total of 83.5% of patients and 93.5% of clinicians use smartphones daily. However, only 25% had ever used an arthritis app and only 5% had persisted with one. Both groups identified managing pain, flares and RA medications as areas of existing need. Access to care, medication support and disease education were mutually agreeable opportunities; however, discrepancies existed between groups with clinicians prioritizing education over access, likely due to concerns of data overwhelm (80.6% considered this a barrier). Conclusions: In spite of high technology use and willingness from both sides, our cohort did not utilize technology to support care, suggesting inadequacies in the existing software. The lack of an objective biomarker for RA disease activity, existing challenges in the healthcare system and the need for integration with existing technical systems were identified as the greatest barriers. Trial registration: Registered on the Clinical Research Network registry (IRAS ID: 264690).

Assessing Serious Spinal Pathology Using Bayesian Network Decision Support: Development and Validation Study.

BACKGROUND: Identifying and managing serious spinal pathology (SSP) such as cauda equina syndrome or spinal infection in patients presenting with low back pain is challenging. Traditional red flag questioning is increasingly criticized, and previous studies show that many clinicians lack confidence in managing patients presenting with red flags. Improving decision-making and reducing the variability of care for these patients is a key priority for clinicians and researchers. OBJECTIVE: We aimed to improve SSP identification by constructing and validating a decision support tool using a Bayesian network (BN), which is an artificial intelligence technique that combines current evidence and expert knowledge. METHODS: A modified RAND appropriateness procedure was undertaken with 16 experts over 3 rounds, designed to elicit the variables, structure, and conditional probabilities necessary to build a causal BN. The BN predicts the likelihood of a patient with a particular presentation having an SSP. The second part of this study used an established framework to direct a 4-part validation that included comparison of the BN with consensus statements, practice guidelines, and recent research. Clinical cases were entered into the model and the results were compared with clinical judgment from spinal experts who were not involved in the elicitation. Receiver operating characteristic curves were plotted and area under the curve were calculated for accuracy statistics. RESULTS: The RAND appropriateness procedure elicited a model including 38 variables in 3 domains: risk factors (10 variables), signs and symptoms (17 variables), and judgment factors (11 variables). Clear consensus was found in the risk factors and signs and symptoms for SSP conditions. The 4-part BN validation demonstrated good performance overall and identified areas for further development. Comparison with available clinical literature showed good overall agreement but suggested certain improvements required to, for example, 2 of the 11 judgment factors. Case analysis showed that cauda equina syndrome, space-occupying lesion/cancer, and inflammatory condition identification performed well across the validation domains. Fracture identification performed less well, but the reasons for the erroneous results are well understood. A review of the content by independent spinal experts backed up the issues with the fracture node, but the BN was otherwise deemed acceptable. CONCLUSIONS: The RAND appropriateness procedure and validation framework were successfully implemented to develop the BN for SSP. In comparison with other expert-elicited BN studies, this work goes a step further in validating the output before attempting implementation. Using a framework for model validation, the BN showed encouraging validity and has provided avenues for further developing the outputs that demonstrated poor accuracy. This study provides the vital first step of improving our ability to predict outcomes in low back pain by first considering the problem of SSP. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21804.

Methods used to evaluate usability of mobile clinical decision support systems for healthcare emergencies: a systematic review and qualitative synthesis.

Objective: The aim of this study was to determine the methods and metrics used to evaluate the usability of mobile application Clinical Decision Support Systems (CDSSs) used in healthcare emergencies. Secondary aims were to describe the characteristics and usability of evaluated CDSSs. Materials and Methods: A systematic literature review was conducted using Pubmed/Medline, Embase, Scopus, and IEEE Xplore databases. Quantitative data were descriptively analyzed, and qualitative data were described and synthesized using inductive thematic analysis. Results: Twenty-three studies were included in the analysis. The usability metrics most frequently evaluated were efficiency and usefulness, followed by user errors, satisfaction, learnability, effectiveness, and memorability. Methods used to assess usability included questionnaires in 20 (87%) studies, user trials in 17 (74%), interviews in 6 (26%), and heuristic evaluations in 3 (13%). Most CDSS inputs consisted of manual input (18, 78%) rather than automatic input (2, 9%). Most CDSS outputs comprised a recommendation (18, 78%), with a minority advising a specific treatment (6, 26%), or a score, risk level or likelihood of diagnosis (6, 26%). Interviews and heuristic evaluations identified more usability-related barriers and facilitators to adoption than did questionnaires and user testing studies. Discussion: A wide range of metrics and methods are used to evaluate the usability of mobile CDSS in medical emergencies. Input of information into CDSS was predominantly manual, impeding usability. Studies employing both qualitative and quantitative methods to evaluate usability yielded more thorough results. Conclusion: When planning CDSS projects, developers should consider multiple methods to comprehensively evaluate usability.

Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients.

BACKGROUND: Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. METHODS: Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. RESULTS: Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16-89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62-2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988-0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986-0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63-8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. CONCLUSIONS: Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.

Inferring biological kinship in ancient datasets: comparing the response of ancient DNA-specific software packages to low coverage data.

BACKGROUND: The inference of biological relations between individuals is fundamental to understanding past human societies. Caregiving, resource sharing and sexual behaviours are often mediated by biological kinship and yet the identification and interpretation of kin relationships in prehistoric human groups is difficult. In recent years, the advent of archaeogenetic techniques have offered a fresh approach, and when combined with more traditional osteological and interpretive archaeological methods, allows for improved interpretation of the burial practices, cultural behaviours, and societal stratification in ancient societies. Although archaeogenetic techniques are developing at pace, questions remain as to their accuracy, particularly when applied to the low coverage datasets that results from the sequencing of DNA derived from highly degraded ancient material. RESULTS: The performance of six of the most commonly used kinship identifcation software methods was explored at a range of low and ultra low genome coverages. An asymmetrical response was observed across packages, with decreased genome coverage resulting in differences in both direction and degree of change of calculated kinship scores and thus pairwise relatedness estimates are dependant on both package used and genome coverage. Methods reliant upon genotype likelihoods methods (lcMLkin, NGSrelate and NGSremix) show a decreased level of prediction at coverage below 1x, although were consistent in the particular relationships identified at these coverages when compared to the pseudohaploid reliant methods tested (READ, the Kennett 2017 method and TKGWV2.0). The three pseudohaploid methods show predictive potential at coverages as low as 0.05x, although the accuracy of the relationships identified is questionable given the increase in the number of relationships identifIed at the low coverage (type I errors). CONCLUSION: Two pseudohaploid methods (READ and Kennett 2017) show relatively consistent inference of kin relationships at low coverage (0.5x), with READ only showing a significant performance drop off at ultralow coverages (< 0.2x). More generally, our results reveal asymmetrical kinship classifications in some software packages even at high coverages, highlighting the importance of applying multiple methods to authenticate kin relationships in ancient material, along with the continuing need to develop laboratory methods that maximise data output for downstream analyses.

Reducing the question burden of patient reported outcome measures using Bayesian networks.

Patient Reported Outcome Measures (PROMs) are questionnaires completed by patients about aspects of their health status. They are a vital part of learning health systems as they are the primary source of information about important outcomes that are best assessed by patients such as pain, disability, anxiety and depression. The volume of questions can easily become burdensome. Previous techniques reduced this burden by dynamically selecting questions from question item banks which are specifically built for different latent constructs being measured. These techniques analyzed the information function between each question in the item bank and the measured construct based on item response theory then used this information function to dynamically select questions by computerized adaptive testing. Here we extend those ideas by using Bayesian Networks (BNs) to enable Computerized Adaptive Testing (CAT) for efficient and accurate question selection on widely-used existing PROMs. BNs offer more comprehensive probabilistic models of the connections between different PROM questions, allowing the use of information theoretic techniques to select the most informative questions. We tested our methods using five clinical PROM datasets, demonstrating that answering a small subset of questions selected with CAT has similar predictions and error to answering all questions in the PROM BN. Our results show that answering 30% - 75% questions selected with CAT had an average area under the receiver operating characteristic curve (AUC) of 0.92 (min: 0.8 - max: 0.98) for predicting the measured constructs. BNs outperformed alternative CAT approaches with a 5% (min: 0.01% - max: 9%) average increase in the accuracy of predicting the responses to unanswered question items.

Usability Testing of a Digital Assessment Routing Tool for Musculoskeletal Disorders: Iterative, Convergent Mixed Methods Study.

BACKGROUND: Musculoskeletal disorders negatively affect millions of patients worldwide, placing significant demand on health care systems. Digital technologies that improve clinical outcomes and efficiency across the care pathway are development priorities. We developed the musculoskeletal Digital Assessment Routing Tool (DART) to enable self-assessment and immediate direction to the right care. OBJECTIVE: We aimed to assess and resolve all serious DART usability issues to create a positive user experience and enhance system adoption before conducting randomized controlled trials for the integration of DART into musculoskeletal management pathways. METHODS: An iterative, convergent mixed methods design was used, with 22 adult participants assessing 50 different clinical presentations over 5 testing rounds across 4 DART iterations. Participants were recruited using purposive sampling, with quotas for age, habitual internet use, and English-language ability. Quantitative data collection was defined by the constructs within the International Organization for Standardization 9241-210-2019 standard, with user satisfaction measured by the System Usability Scale. Study end points were resolution of all grade 1 and 2 usability problems and a mean System Usability Scale score of ≥80 across a minimum of 3 user group sessions. RESULTS: All participants (mean age 48.6, SD 15.2; range 20-77 years) completed the study. Every assessment resulted in a recommendation with no DART system errors and a mean completion time of 5.2 (SD 4.44, range 1-18) minutes. Usability problems were reduced from 12 to 0, with trust and intention to act improving during the study. The relationship between eHealth literacy and age, as explored with a scatter plot and calculation of the Pearson correlation coefficient, was performed for all participants (r=-0.2; 20/22, 91%) and repeated with a potential outlier removed (r=-0.23), with no meaningful relationships observed or found for either. The mean satisfaction for daily internet users was highest (19/22, 86%; mean 86.5, SD 4.48; 90% confidence level [CL] 1.78 or -1.78), with nonnative English speakers (6/22, 27%; mean 78.1, SD 4.60; 90% CL 3.79 or -3.79) and infrequent internet users scoring the lowest (3/22, 14%; mean 70.8, SD 5.44; 90% CL 9.17 or -9.17), although the CIs overlap. The mean score across all groups was 84.3 (SD 4.67), corresponding to an excellent system, with qualitative data from all participants confirming that DART was simple to use. CONCLUSIONS: All serious DART usability issues were resolved, and a good level of satisfaction, trust, and willingness to act on the DART recommendation was demonstrated, thus allowing progression to randomized controlled trials that assess safety and effectiveness against usual care comparators. The iterative, convergent mixed methods design proved highly effective in fully evaluating DART from a user perspective and could provide a blueprint for other researchers of mobile health systems. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/27205.

Central Nervous System Metabolism in Autism, Epilepsy and Developmental Delays: A Cerebrospinal Fluid Analysis.

Neurodevelopmental disorders are associated with metabolic pathway imbalances; however, most metabolic measurements are made peripherally, leaving central metabolic disturbances under-investigated. Cerebrospinal fluid obtained intraoperatively from children with autism spectrum disorder (ASD, n = 34), developmental delays (DD, n = 20), and those without known DD/ASD (n = 34) was analyzed using large-scale targeted mass spectrometry. Eighteen also had epilepsy (EPI). Metabolites significantly related to ASD, DD and EPI were identified by linear models and entered into metabolite-metabolite network pathway analysis. Common disrupted pathways were analyzed for each group of interest. Central metabolites most involved in metabolic pathways were L-cysteine, adenine, and dodecanoic acid for ASD; nicotinamide adenine dinucleotide phosphate, L-aspartic acid, and glycine for EPI; and adenosine triphosphate, L-glutamine, ornithine, L-arginine, L-lysine, citrulline, and L-homoserine for DD. Amino acid and energy metabolism pathways were most disrupted in all disorders, but the source of the disruption was different for each disorder. Disruption in vitamin and one-carbon metabolism was associated with DD and EPI, lipid pathway disruption was associated with EPI and redox metabolism disruption was related to ASD. Two microbiome metabolites were also detected in the CSF: shikimic and cis-cis-muconic acid. Overall, this study provides increased insight into unique metabolic disruptions in distinct but overlapping neurodevelopmental disorders.

mHealth apps for gestational diabetes mellitus that provide clinical decision support or artificial intelligence: A scoping review.

AIMS: Gestational diabetes (GDM) is the most common metabolic disorder of pregnancy, requiring complex management and empowerment of those affected. Mobile health (mHealth) applications (apps) are proposed for streamlining healthcare service delivery, extending care relationships into the community, and empowering those affected by prolonged medical disorders to be equal collaborators in their healthcare. This review investigates mHealth apps intended for use with GDM; specifically those powered by artificial intelligence (AI) or providing decision support. METHODS: A scoping review using the novel Survey Tool approach for collaborative literature Reviews (STaR) process was performed. RESULTS: From 18 papers, 11 discrete GDM-based mHealth apps were identified, but only 3 were reasonably mature with only one currently in use in a clinical setting. Two-thirds of the apps provided condition-relevant contextual user feedback that could aid in patient self care. However, although each app targeted one or more components of the GDM clinical pathway, no app addressed the entirety from diagnosis to postpartum. CONCLUSIONS: There are limited mHealth apps for GDM that incorporate AI or AI-based decision support. Many exist only to record patient information like blood glucose readings or diet, provide generic patient education or advice, or to reduce adverse events by providing medication or appointment alerts. Significant barriers remain that continue to limit the adoption of mHealth apps in clinical care settings. Further research and development are needed to deliver intelligent holistic mHealth apps using AI that can truly reduce healthcare resource use and improve outcomes by enabling patient self care in the community.

Using Structural Equation Modelling in Routine Clinical Data on Diabetes and Depression: Observational Cohort Study.

BACKGROUND: Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of "research-friendly" clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. OBJECTIVE: SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. METHODS: Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. RESULTS: The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (ß=.034, P<.001) and increased A&E use (ß=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (ß=-.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (ß=-.072, P<.001), having depression (ß=.018, P=.007), and receiving mental health treatment (ß=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. CONCLUSIONS: Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set.

Validation of a Musculoskeletal Digital Assessment Routing Tool: Protocol for a Pilot Randomized Crossover Noninferiority Trial.

BACKGROUND: Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing demand for health care use. Digital technologies to improve health care outcomes and efficiency are considered a priority; however, innovations are rarely tested with sufficient rigor in clinical trials, which is the gold standard for clinical proof of safety and efficacy. We have developed a new musculoskeletal digital assessment routing tool (DART) that allows users to self-assess and be directed to the right care. DART requires validation in a real-world setting before implementation. OBJECTIVE: This pilot study aims to assess the feasibility of a future trial by exploring the key aspects of trial methodology, assessing the procedures, and collecting exploratory data to inform the design of a definitive randomized crossover noninferiority trial to assess DART safety and effectiveness. METHODS: We will collect data from 76 adults with a musculoskeletal condition presenting to general practitioners within a National Health Service (NHS) in England. Participants will complete both a DART assessment and a physiotherapist-led triage, with the order determined by randomization. The primary analysis will involve an absolute agreement intraclass correlation (A,1) estimate with 95% CI between DART and the clinician for assessment outcomes signposting to condition management pathways. Data will be collected to allow the analysis of participant recruitment and retention, randomization, allocation concealment, blinding, data collection process, and bias. In addition, the impact of trial burden and potential barriers to intervention delivery will be considered. The DART user satisfaction will be measured using the system usability scale. RESULTS: A UK NHS ethics submission was done during June 2021 and is pending approval; recruitment will commence in early 2022, with data collection anticipated to last for 3 months. The results will be reported in a follow-up paper in 2022. CONCLUSIONS: This study will inform the design of a randomized controlled crossover noninferiority study that will provide evidence concerning mobile health DART system clinical signposting in an NHS setting before real-world implementation. Success should produce evidence of a safe, effective system with good usability, potentially facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This rigorous approach to mobile health system testing could be used as a guide for other developers of similar applications. TRIAL REGISTRATION: ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/31541.

Bayesian networks in healthcare: What is preventing their adoption?

There has been much research effort expended toward the use of Bayesian networks (BNs) in medical decision-making. However, because of the gap between developing an accurate BN and demonstrating its clinical usefulness, this has not resulted in any widespread BN adoption in clinical practice. This paper investigates this problem with the aim of finding an explanation and ways to address the problem through a comprehensive literature review of articles describing BNs in healthcare. Based on the literature collection that has been systematically narrowed down from 3810 to 116 most relevant articles, this paper analyses the benefits, barriers and facilitating factors (BBF) for implementing BN-based systems in healthcare using the ITPOSMO-BBF framework. A key finding is that works in the literature rarely consider barriers and even when these were identified they were not connected to facilitating factors. The main finding is that the barriers can be grouped into: (1) data inadequacies; (2) clinicians' resistance to new technologies; (3) lack of clinical credibility; (4) failure to demonstrate clinical impact; (5) absence of an acceptable predictive performance; and (6) absence of evidence for model's generalisability. The facilitating factors can be grouped into: (1) data collection improvements; (2) software and technological improvements; (3) having interpretable and easy to use BN-based systems; (4) clinical involvement in the development or review of the model; (5) investigation of model's clinical impact; (6) internal validation of the model's performance; and (7) external validation of the model. These groupings form a strong basis for a generic framework that could be used for formulating strategies for ensuring BN-based clinical decision-support system adoption in frontline care settings. The output of this review is expected to enhance the dialogue among researchers by providing a deeper understanding for the neglected issue of BN adoption in practice and promoting efforts for implementing BN-based systems.

Usability Testing of a Digital Assessment Routing Tool: Protocol for an Iterative Convergent Mixed Methods Study.

BACKGROUND: Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on millions of patients and an increasing burden on health care utilization. Digital technologies that improve health care outcomes and efficiency are considered a priority; however, innovations are often inadequately developed and poorly adopted. Further, they are rarely tested with sufficient rigor in clinical trials-the gold standard for clinical proof of efficacy. We have developed a new musculoskeletal Digital Assessment Routing Tool (DART) that allows users to self-assess and be directed to the right care. DART requires usability testing in preparation for clinical trials. OBJECTIVE: This study will use the iterative convergent mixed methods design to assess and mitigate all serious usability issues to optimize user experience and adoption. Using this methodology, we will provide justifiable confidence to progress to full-scale randomized controlled trials when DART is integrated into clinical management pathways. This study protocol will provide a blueprint for future usability studies of mobile health solutions. METHODS: We will collect qualitative and quantitative data from 20-30 participants aged 18 years and older for 4 months. The exact number of participants recruited will be dependent on the number of iterative cycles required to reach the study end points. Building on previous internal testing and stakeholder involvement, quantitative data collection is defined by the constructs within the ISO 9241-210-2019 standard and the system usability scale, providing a usability score for DART. Guided by the participant responses to quantitative questioning, the researcher will focus the qualitative data collection on specific usability problems. These will then be graded to provide the rationale for further DART system improvements throughout the iterative cycles. RESULTS: This study received approval from the Queen Mary University of London Ethics of Research Committee (QMREC2018/48/048) on June 4, 2020. At manuscript submission, study recruitment was on-going, with data collection to be completed and results published in 2021. CONCLUSIONS: This study will provide evidence concerning mobile health DART system usability and acceptance determining system improvements required to support user adoption and minimize suboptimal system usability as a potential confounder within subsequent noninferiority clinical trials. Success should produce a safe effective system with excellent usability, facilitating quicker and easier patient access to appropriate care while reducing the burden on primary and secondary care musculoskeletal services. This deliberately rigorous approach to mobile health innovation could be used as a guide for other developers of similar apps. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/27205.

Isolation and characterization of a halophilic Modicisalibacter sp. strain Wilcox from produced water.

We report the isolation a halophilic bacterium that degrades both aromatic and aliphatic hydrocarbons as the sole sources of carbon at high salinity from produced water. Phylogenetic analysis of 16S rRNA-gene sequences shows the isolate is a close relative of Modicisalibacter tunisiensis isolated from an oil-field water in Tunisia. We designate our isolate as Modicisalibacter sp. strain Wilcox. Genome analysis of strain Wilcox revealed the presence of a repertoire of genes involved in the metabolism of aliphatic and aromatic hydrocarbons. Laboratory culture studies corroborated the predicted hydrocarbon degradation potential. The strain degraded benzene, toluene, ethylbenzene, and xylenes at salinities ranging from 0.016 to 4.0 M NaCl, with optimal degradation at 1 M NaCl. Also, the strain degraded phenol, benzoate, biphenyl and phenylacetate as the sole sources of carbon at 2.5 M NaCl. Among aliphatic compounds, the strain degraded n-decane and n-hexadecane as the sole sources of carbon at 2.5 M NaCl. Genome analysis also predicted the presence of many heavy metal resistance genes including genes for metal efflux pumps, transport proteins, and enzymatic detoxification. Overall, due to its ability to degrade many hydrocarbons and withstand high salt and heavy metals, strain Wilcox may prove useful for remediation of produced waters.