Pediatric Rome IV diagnosis agreement is greater than agreement on diagnostic testing.

BACKGROUND: Pediatric Rome IV criteria are used to diagnose childhood functional gastrointestinal disorders (FGIDs). This study of pediatric gastroenterology physicians measured their agreement in (1) Making a pediatric Rome IV FGID diagnosis; and (2) Diagnostic testing for patients with FGIDs. METHODS: Pediatric gastroenterologists and pediatric gastroenterology fellows at two medical centers completed a survey containing clinical FGID vignettes. For each vignette, raters identified the most likely Rome IV diagnosis(es) and selected which diagnostic test(s) (if any) they typically would obtain. The survey was re-administered within 3 months. Inter-rater and intra-rater weighted percent agreement was determined. Linear mixed modeling identified sources of variability in diagnostic testing. KEY RESULTS: Thirty-four raters completed the initial survey of whom thirty-one (91%) completed the repeat survey. Overall inter-rater agreement on Rome IV diagnoses was 68% for initial and repeat surveys whereas intra-rater agreement was 76%. In contrast, overall inter-rater agreement on diagnostic testing was <30% for both initial and repeat surveys and intra-rater agreement was only 57%. Between-physician differences accounted for 43% of the variability in the number of tests selected. Rater identified use of Rome criteria in clinical practice was associated with 1.1 fewer diagnostic tests on average (95% CI 0.2-2.0, p = 0.015). Higher intra-rater agreement was noted for diagnostic testing in faculty when compared to fellows (p = 0.009). CONCLUSIONS & INFERENCES: In a multicenter evaluation among pediatric gastroenterology physicians, pediatric Rome IV diagnostic agreement was higher than that reported for previous Rome versions, and higher than agreement on diagnostic testing.

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists.

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Traducción al español y propuesta de modificación de la clasificación de lesiones deportivas Orchard Sports Injury Classification System (OSICS) Versión 12 / Translation into Spanish and proposal to modify the Orchard Sports Injury Classification System (OSICS) Version 12 / Tradução para o espanhol e proposta de modificação do Sistema de Classificação de Lesões Esportivas Orchard (OSICS) Versão 12

OBJETIVO: dar a conocer la traducción al español de la Versión 12 del sistema de clasificación de lesiones deportivas denominado Orchard Sports Injury Classification System y proponer una modificación del mismo para incluir un código numérico que refleje la repercusión de la lesión en la funcionalidad deportiva. MÉTODO: los miembros del grupo de trabajo sobre la epidemiología de la lesión deportiva, del Grupo de Estudio del Sistema Músculo-Tendón, de la Sociedad Española de Traumatología del Deporte, llevaron a cabo una revisión bibliográfica sobre los sistemas de clasificación epidemiológica de las lesiones, tres reuniones presenciales de consenso y diversos trabajos en línea, siguiendo la metodología de trabajo DELPHI. RESULTADOS: La traducción al español de la versión 12 del sistema Orchard Sports Injury Classification System está accesible de forma completa y gratuita en: https://gesmute.es/traduccion-espanola-osics-12/. Se propone añadir, al final de la codificación actual de la versión 12, un código numérico (0: Sin afectación Funcional; 1: Limita Actividad Deportiva; 2: Impide Actividad Deportiva; 3: Limita Actividades Vida Cotidiana), para indicar la repercusión funcional que produce la lesión. CONCLUSIONES: presentamos la traducción al español de la versión 12 del sistema de clasificación de lesiones Orchard Sports Injury Classification System. Proponemos como mejora la inclusión de criterios de funcionalidad en las clasificaciones de lesiones deportivas, nuestra propuesta podría suponer una mejora al Orchard Sports Injury Classification System versión 12

OBJECTIVE: to publicize the Spanish translation of Version 12 of the sports injury classification system called Orchard Sports Injury Classification System and to propose a modification to include a numerical code that reflects the impact of the injury on sports functionality. METHOD: the members of the working group on the epidemiology of sports injury, of the Study Group of the Muscle-Tendon System, of the Spanish Society of Sports Traumatology, carried out a bibliographic review on the epidemiological classification systems of injuries, three face-to-face consensus meetings and various online works, following the DELPHI work methodology. RESULTS: The Spanish translation of version 12 of the Orchard Sports Injury Classification System is accessible completely and free of charge at: https://gesmute.es/traduccion-espanola-osics-12/. It is proposed to add, at the end of the current coding of version 12, a numerical code (0: No Functional impairment; 1: Limits Sports Activity; 2: Prevents Sports Activity; 3: Limits Daily Life Activities), to indicate the functional repercussion that produces the injury. CONCLUSIONS: We present the Spanish translation of version 12 of the Orchard Sports Injury Classification System. We propose as an improvement the inclusion of functionality criteria in sports injury classifications, our proposal could be an improvement to the Orchard Sports Injury Classification System version 12

OBJETIVO: apresentar a tradução em espanhol da versão 12 do sistema de classificação de lesões esportivas, denominado Orchard Sports Injury Classification System, e propor uma modificação para incluir um código numérico que reflita o impacto da lesão na funcionalidade esportiva. MÉTODO: os membros do grupo de trabalho sobre epidemiologia da lesão esportiva, do Grupo de Estudo do Sistema Músculo-Tendão, da Sociedade Espanhola de Traumatologia Esportiva, realizaram uma revisão bibliográfica sobre os sistemas de classificação epidemiológica das lesões. , três reuniões de consenso presenciais e vários trabalhos on-line, seguindo a metodologia de trabalho DELPHI. RESULTADOS: A tradução para o espanhol da versão 12 do Sistema de classificação de lesões esportivas da Orchard pode ser acessada completamente e gratuitamente em: https://gesmute.es/traduccion-espanola-osics-12/ Propõe-se adicionar, ao final da codificação atual da versão 12, um código numérico (0: Sem comprometimento funcional; 1: Limita a atividade esportiva; 2: Impede a atividade esportiva; 2: Impede a atividade esportiva; 3: Limita a atividade diária), para indicar a repercussão funcional que produz a lesão. CONCLUSÕES: Apresentamos a tradução em espanhol da versão 12 do Orchard Sports Injury Classification System. Propomos como melhoria a inclusão de critérios de funcionalidade nas classificações de lesões esportivas; nossa proposta poderia ser uma melhoria na versão 12 do Orchard Sports Injury Classification System

Nomenclátor jerarquizado en reumatología / Hierarchical nomenclature in rheumatology

INTRODUCCIÓN: Una misión de la Sociedad Española de Reumatología es aportar las herramientas necesarias para alcanzar la excelencia asistencial. En la actualidad no existe una referencia que cuantifique la complejidad de los actos médicos de esta especialidad. MATERIAL Y MÉTODO: Se elaboró una relación de los actos propios del reumatólogo y se estableció un sistema de clasificación jerárquica a partir de la construcción de un índice de complejidad, calculado mediante el tiempo de realización y el grado de dificultad de cada acto. RESULTADOS: Los resultados del método Delphi tendieron a una opinión grupal consensuada (media σ2 - σ1=0,75-1,43=-0,68, media IQR2 - IQR1=0,8-1,9=-1,1). El rango de valores del índice de complejidad osciló de 48 a 465 puntos. Entre las consultas, las que alcanzaron mayor gradación fueron la primera visita al paciente hospitalizado (366) y la visita a domicilio (369). Entre las técnicas diagnósticas, destacaron las biopsias. Las que puntuaron más alto fueron: biopsia ósea (465), de nervio sural (416) y sinovial (380). La ecografía tuvo una puntuación de 204, la capilaroscopia de 113 y la densitometría de 112. Entre las técnicas terapéuticas, la máxima dificultad (388), la alcanzó la infiltración/artrocentesis/ inyección articular infantil. La puntuación de la inyección articular con control ecográfico fue de 163. El informe clínico de minusvalía, 323 y el informe pericial, 370. CONCLUSIONES: Este trabajo ha permitido elaborar un nomenclátor de 54 actos en reumatología donde se identifican como actos más complejos la realización de biopsias (ósea, nervio sural, sinovial), la visita a paciente hospitalizado, la visita a domicilio, la infiltración infantil bajo sedación y la elaboración de un informe pericial. La ecografía osteomuscular es considerada el doble de compleja de una visita sucesiva, la capilaroscopia o la densitometría ósea

INTRODUCTION: One of the missions of the Spanish Society of Rheumatology is to provide the necessary tools for excellence in health care. Currently, there is no reference point to quantify medical actions in this specialty, and this is imperative. MATERIAL AND METHOD: A list of actions was drawn up and a hierarchical classification system was established by developing a complexity index, calculated based on the completion time and difficulty level of each action. RESULTS: The results of the Delphi method tended to the consensus opinion within a group (mean σ2 - σ1=0.75-1.43=-0.68, mean IQR2 - IQR1=0.8-1.9=-1.1). The values of the complexity index ranged between 48 and 465 points. Among consultation actions, those reaching the highest scores were the first inpatient visit (366) and visits to the patient's home (369). Among diagnostic techniques, biopsies were prominent, those with the highest score were: bone biopsy (465), sural nerve biopsy (416) and synovial biopsy (380). Ultrasound scan scored 204, capillaroscopy 113 and densitometry 112. Among therapeutic techniques, infiltration/ arthrocentesis/articular injection in children reached the highest difficulty (388). The score for ultrasound-guided articular injection was 163. The score for clinical report on disability was 323 and expert report 370. CONCLUSIONS: A nomenclature of 54 actions in Rheumatology was compiled. Biopsies (bone, sural nerve, synovial), inpatient visits, visits to the patient's home, infiltrations in children, and the preparation of the expert report were identified as the most complex actions. Musculoskeletal ultrasound is twice as complex as subsequent visits, capillaroscopy or bone densitometry

[French adaptation of motor function scales for patients with spinal muscular atrophy]. / SMA: Des échelles d'évaluation motrice pour le public francophone.

TITLE: SMA: Des échelles d'évaluation motrice pour le public francophone. ABSTRACT: À l'heure des nouvelles thérapeutiques chez les personnes présentant une amyotrophie spinale antérieure ou spinal muscular atrophy (SMA), la mesure régulière, précise et fiable des capacités motrices est devenue indispensable. Différents outils ont été développés dans la littérature et peuvent être utilisés pour cela. Le choix d'une échelle/ d'un outil se fait en fonction du type de SMA, de l'âge de la personne et des éléments spécifiques de la motricité que l'on souhaite évaluer. En France, l'échelle MFM est utilisée en pratique clinique dans de nombreux centres de référence de Maladies Neuromusculaires (MNM). Les autres échelles fréquemment utilisées au niveau international ne sont cependant pas disponibles en français rendant leur utilisation plus difficile en pratique clinique courante. Cet article présente le processus de traduction en français des échelles les plus fréquemment utilisées chez la personne avec SMA (CHOP INTEND, HFMSE, RULM, 6-minute walk test et HINE-2). Différentes étapes ont été respectées, notamment les étapes de traduction en français, traduction inversée en anglais, comparaison des versions anglaises, harmonisation et obtention de la version finale en français. Un programme de formation et sensibilisation des différents professionnels des consultations MNM des centres de référence français avec proposition d'ateliers en présence des membres du comité scientifique suivra l'étape de traduction afin de les faire connaître, expliciter leur utilisation et participer à la diffusion de ce travail.

Real-world testing and treatment patterns in chronic lymphocytic leukemia: A SEER patterns of care analysis.

BACKGROUND: Laboratory testing and treatments for chronic lymphocytic leukemia (CLL) have changed dramatically within the last decade. The authors evaluated changes in patterns of real-world testing and treatment over time by comparing 2 population-based cohorts. METHODS: The National Cancer Institute-sponsored Patterns of Care study was conducted among patients with CLL who were sampled from 14 Surveillance, Epidemiology, and End Results (SEER) program registries. Demographics, testing, and treatment data were abstracted from medical records within 24 months of diagnosis. RESULTS: A total of 1008 patients diagnosed in 2008 and 1367 patients diagnosed in 2014 were included. There was a significant increase in fluorescence in situ hybridization (FISH) testing, immunoglobulin heavy-chain variable region gene (IgVH ) mutation analyses, and lymph node biopsies between 2008 and 2014. FISH testing was performed in the majority of, but not all, treated patients (53% in 2008, which increased to 62% in 2014). Some differences in the receipt of FISH testing by age and insurance status were observed over time (older patients and Medicare patients without private insurance were less likely to be tested in 2014). There were contrasting testing patterns noted by practice type and year, with nonteaching hospitals more likely to perform bone marrow biopsies in 2008, and teaching hospitals more likely to perform FISH and IgVH testing in 2014. There also were differences in treatments over time, with the use of bendamustine and rituximab being more common in 2014, at the expense of fludarabine, cyclophosphamide, and rituximab. CONCLUSIONS: There have been rapidly changing practices in the testing and treatment patterns of patients with CLL within the last decade.

Diagnostic parameters in periprosthetic infections: the current state of the literature.

Despite progress in recent years, a definitive diagnosis of PPI is not yet possible. Due to new diagnostic possibilities and the further development of already existing diagnostic tools, a more accurate diagnostic clarification of uncertain cases should be possible. The following article includes an overview of common existing diagnostic tools and instruments, which will likely gain importance in the future.

Isquemia mesentérica: algoritmos diagnósticos y terapéuticos / Mesenteric ischaemia: Diagnosis and therapeutic algorithms

La isquemia mesentérica se caracteriza por una reducción del flujo sanguíneo a nivel intestinal, de forma brusca o de forma progresiva, con unas consecuencias potencialmente letales, sobre todo en los casos agudos. La falta de evidencia científica ante una enfermedad poco frecuente, con una clínica y pruebas diagnósticas en ocasiones inespecíficas, y la gran heterogeneidad en los procedimientos de revascularización hacen difícil la toma de decisiones. Las sociedades científicas deben estimular el desarrollo de algoritmos diagnósticos y terapéuticos con el fin de mejorar el manejo y la supervivencia de estos pacientes y, por otro lado, avalar la actividad de sus miembros. Es, en este marco, donde la SOciedad Castellano Leonesa de Angiología y CIrugía VAScular (SOCLACIVAS) se propuso establecer un algoritmo diagnóstico y terapéutico en la isquemia mesentérica

Mesenteric ischaemia is characterised by a sudden or gradual reduction in blood flow at intestinal level, with some potentially fatal consequences, particularly in acute cases. The lack of scientific evidence of a rare disease, with a clinical picture and diagnostic tests that are occasionally non-specific, as well as a wide variation in revascularisation procedures, make it difficult to make decisions. The scientific societies must stimulate the development of diagnostic and therapeutic algorithms, with the aim of improving the management and survival of these patients, as well as to endorse the activities of their members. It is within this framework that the Angiology and Vascular Surgery Society of Castile and Leon (Sociedad Castellano Leonesa de Angiología y Cirugía Vascular) (SOCLACIVAS) proposes to establish a diagnostic and therapeutic algorithm for mesenteric ischaemia

El papel de la autopsia en la práctica clínica actual / The current role of autopsy in current clinical practice

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Identificación rápida de microorganismos de frascos de hemocultivos por espectrometría de masas: Comparación de 2 procedimientos diagnósticos / Rapid identification of microorganisms by mass spectrometry in a blood culture system: Comparison of two procedures

La identificación rápida de microorganismos es crítica, en especial en pacientes sépticos hospitalizados. La espectrometría de masas conocida como matrix-assisted laser desorption/ionization time-of- flight mass spectrometry (MALDI-TOF MS) permite la identificación directa desde botellas de hemocultivos positivos en forma rápida y sencilla. Este estudio evaluó el desempeño del procedimiento basado en el sistema MALDI Biotyper que utiliza el kit comercial MALDI Sepsityper de Bruker Daltonics (en adelante, MS) frente a uno artesanal (en adelante, HF). Se procesaron 840 botellas de hemocultivos positivos con HF y 542 de estas fueron evaluadas también con MS. Se logró la identificación de los microorganismos en 670 (79,76 %) y 391 (72,14 %) botellas, respectivamente (p = 0,0013). Se demostró la efectividad de ambos procedimientos para la identificación de microorganismos desde frascos de hemocultivos positivos. Sin embargo, el procedimiento HF fue superior al MS, en especial frente a bacterias gram positivas.

Rapid identification of microorganisms is critical in hospitalized infected patients. Blood culture is currently the gold standard for detecting and identifying microorganisms causing bacteremia or sepsis. The introduction of mass spectrometry by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF MS) in microbiology laboratories, especially in microorganisms growing in blood culture bottles, provides rapid identification. This study evaluates the performance of the Maldi Sepsityper Biotyper procedure (hereinafter, MS) compared to that of an in-home method (hereinafter, HF). Eight hundred and forty (840) positive blood culture bottles were processed using the HF procedure, 542 of which were also processed using MS. The organisms were identified in 670 (79. 76 %) and 391 (72. 14 %) bottles respectively (p = 0,0013). This study demonstrates the effectiveness of both procedures for identifying microorganisms directly from positive blood culture bottles. However, the HF procedure proved to be more effective than MS, especially in the presence of Gram positive organisms.

[Benefit assessment of diagnostic procedures: quo vadimus?]. / Nutzenbewertung diagnostischer Maßnahmen - quo vadimus?

Not only therapeutic procedures, but also diagnostic procedures, have to demonstrate their patient-relevant benefits if they are to be reimbursed by public health insurance. Randomized trials comparing two diagnostic procedures allow us to assess these benefits directly if appropriate outcomes are used. However, owing to the widespread lack of such studies, it is now necessary to use the "linked evidence" approach as well, trying to predict the patient-relevant benefits from the results of comparative accuracy studies. Such a prediction is based on explicitly specifying our expectations with regard to the consequences of a change in diagnosis at the level of a single patient. We discuss the basic properties of these two approaches, which are relevant to the understanding of their possible role in the benefit assessment of diagnostic procedures. We try to predict the future roles of the two approaches and outline some of the issues on which a consensus is required to allow their successful use in benefit assessment. Furthermore, we indicate some of the developments related to the paradigm of individualized care that may influence the use of benefit assessments for diagnostic studies in the future.

[Clinical and ethical differences between diagnosing and screening].

Screening is often defined as systematic examinations of healthy citizens to identify those with asymptomatic disease. In our modern society many persons have chronic conditions and it is not so easy to draw the line between healthy and unhealthy citizens. Today, many health-care activities aim at detecting conditions at an early non-symptomatic stage of the disease process in order to be able to avoid possible progression to the next stage. On this basis, we suggest to broaden the definition of screening to reflect the realities of modern health care.

[Medical assessments and measurements in ELSA-Brasil]. / Aferições e exames clínicos realizados nos participantes do ELSA-Brasil.

The article describes assessments and measurements performed in the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). Some assessments including anthropometric assessment, casual blood pressure measurement, and ankle-brachial index have an established clinical application while others including pulse wave velocity, heart rate variability, and carotid intima-media thickness have no established application and do not have reference values for healthy Brazilian population but may be important predictors of cardiovascular outcomes. Blood pressure measurement following postural change maneuver was included in the ELSA-Brasil because it has not been much tested in epidemiological studies. Innovative approaches were developed for assessing the ankle-brachial index using an automatic device instead of the mercury column to measure blood pressure and for assessing the anterior-posterior diameter of the right lobe of the liver by ultrasound for quantitative assessment of nonalcoholic fatty liver disease. All ELSA-Brasil subjects were younger (35 years or more) than those included in other cohorts studying subclinical atherosclerosis. The inclusion of younger individuals and a variety of assessments make the ELSA-Brasil a relevant epidemiology study nationwide and worldwide.

Reliability, completeness and accuracy of cleft subphenotyping as recorded on the CLEFTSiS (Cleft Service in Scotland) electronic patient record.

OBJECTIVES: The CLEFTSiS (Cleft Service in Scotland) electronic patient record (EPR) contains pre-surgical photographs among other records and this study proposes to assess the reliability of diagnosis and accuracy of the type and extent of cleft. DESIGN AND SETTING: Retrospective study, University of Dundee. MATERIALS AND METHODS: From all 1092 cases contained by the CLEFTSiS EPR from inception (April 2000) until September 2011; syndromic, atypical and submucous clefts, still births, abortuses, cases with non-cleft velopharyngeal incompetence, Pierre Robin Sequence, or Simonart's bands were excluded to leave 730 case records for analysis. Observer 1 recorded the LAHSAL subphenotype using the pre-surgical photographs for each case. Images that were absent, only partially demonstrated the intended anatomical site or were unclear were excluded. The data for Observer 1 was compared to the EPR subphenotype using the Kappa statistic. Thirty randomly selected cases were recoded one month later to calculate intra-observer reliability and three further observers subphenotyped these cases to determine inter-examiner reliability, both using Kappa statistics. RESULTS: Intra- and inter-observer reliability of the LAHSAL system were excellent (0.809-0.992). The correspondence between Observer 1 and the original CLEFTSiS subphenotype was almost perfect (0.812-0.862) except the soft palate and the left alveolus, where agreement was substantial (0.638-0.776). Only 68 (9.3%) of the records fully demonstrated all six anatomical areas of the LAHSAL coding system with intra-oral images being the most frequently deficient views. CONCLUSIONS: The subphenotype data held on the CLEFTSiS EPR is accurate but incomplete. Only 9.3% of cases contained all relevant pre-surgical photographs. Subphenotyping using the LAHSAL classification has a high degree of intra- and inter-observer reliability.

Afericoes e exames clinicos realizados nos participantes do ELSA-Brasil / Medical assessments and measurements in ELSA-Brasil

Este artigo descreve os exames clínicos realizados no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Alguns deles (antropometria, pressão arterial e índice tornozelo-braquial) já têm uso clínico consolidado. Outros, como a velocidade de onda de pulso, variabilidade da frequência cardíaca e medida da espessura médio-intimal de carótidas, carecem de valor de referência na população brasileira não doente e podem constituir preditores importantes de desfechos cardiovasculares. A medida da pressão arterial após manobra postural foi incluída no ELSA-Brasil porque foi pouco testada em estudos epidemiológicos. O ELSA-Brasil inovou na realização do índice tornozelo-braquial, ao usar um aparelho automático em substituição à coluna de mercúrio na medida da pressão arterial, e também na medida do diâmetro ântero-posterior do lobo direito do fígado pela ultrassonografia, proposta para avaliação quantitativa da doença hepática gordurosa não-alcoólica. Os participantes são indivíduos mais jovens (a partir dos 35 anos) do que em outras coortes focadas no estudo da aterosclerose subclínica. A inclusão de indivíduos mais jovens e a diversidade dos exames realizados tornam o ELSA-Brasil um estudo relevante no contexto da epidemiologia brasileira e internacional.

The article describes assessments and measurements performed in the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). Some assessments including anthropometric assessment, casual blood pressure measurement, and ankle-brachial index have an established clinical application while others including pulse wave velocity, heart rate variability, and carotid intima-media thickness have no established application and do not have reference values for healthy Brazilian population but may be important predictors of cardiovascular outcomes. Blood pressure measurement following postural change maneuver was included in the ELSA-Brasil because it has not been much tested in epidemiological studies. Innovative approaches were developed for assessing the ankle-brachial index using an automatic device instead of the mercury column to measure blood pressure and for assessing the anterior-posterior diameter of the right lobe of the liver by ultrasound for quantitative assessment of nonalcoholic fatty liver disease. All ELSA-Brasil subjects were younger (35 years or more) than those included in other cohorts studying subclinical atherosclerosis. The inclusion of younger individuals and a variety of assessments make the ELSA-Brasil a relevant epidemiology study nationwide and worldwide.

Auditing consistency and usefulness of LOINC use among three large institutions - using version spaces for grouping LOINC codes.

OBJECTIVES: We wanted to develop a method for evaluating the consistency and usefulness of LOINC code use across different institutions, and to evaluate the degree of interoperability that can be attained when using LOINC codes for laboratory data exchange. Our specific goals were to: (1) Determine if any contradictory knowledge exists in LOINC. (2) Determine how many LOINC codes were used in a truly interoperable fashion between systems. (3) Provide suggestions for improving the semantic interoperability of LOINC. METHODS: We collected Extensional Definitions (EDs) of LOINC usage from three institutions. The version space approach was used to divide LOINC codes into small sets, which made auditing of LOINC use across the institutions feasible. We then compared pairings of LOINC codes from the three institutions for consistency and usefulness. RESULTS: The number of LOINC codes evaluated were 1917, 1267 and 1693 as obtained from ARUP, Intermountain and Regenstrief respectively. There were 2022, 2030, and 2301 version spaces among ARUP and Intermountain, Intermountain and Regenstrief and ARUP and Regenstrief respectively. Using the EDs as the gold standard, there were 104, 109 and 112 pairs containing contradictory knowledge and there were 1165, 765 and 1121 semantically interoperable pairs. The interoperable pairs were classified into three levels: (1) Level I - No loss of meaning, complete information was exchanged by identical codes. (2) Level II - No loss of meaning, but processing of data was needed to make the data completely comparable. (3) Level III - Some loss of meaning. For example, tests with a specific 'method' could be rolled-up with tests that were 'methodless'. CONCLUSIONS: There are variations in the way LOINC is used for data exchange that result in some data not being truly interoperable across different enterprises. To improve its semantic interoperability, we need to detect and correct any contradictory knowledge within LOINC and add computable relationships that can be used for making reliable inferences about the data. The LOINC committee should also provide detailed guidance on best practices for mapping from local codes to LOINC codes and for using LOINC codes in data exchange.

Activities identification for activity-based cost/management applications of the diagnostics outpatient procedures.

One of the most challenging problems facing healthcare providers is to determine the actual cost for their procedures, which is important for internal accounting and price justification to insurers. The objective of this paper is to find suitable categories to identify the diagnostic outpatient medical procedures and translate them from functional orientation to process orientation. A hierarchal task tree is developed based on a classification schema of procedural activities. Each procedure is seen as a process consisting of a number of activities. This makes a powerful foundation for activity-based cost/management implementation and provides enough information to discover the value-added and non-value-added activities that assist in process improvement and eventually may lead to cost reduction. Work measurement techniques are used to identify the standard time of each activity at the lowest level of the task tree. A real case study at a private hospital is presented to demonstrate the proposed methodology.

¿Hacia el diagnóstico pragmático?. Reto para el patólogo de los nuevos tiempos / No disponible

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Resources medical students use to derive a differential diagnosis.

BACKGROUND: Deriving an appropriate differential diagnosis is a key clinical competency, but there is little data available on how medical students learn this skill. Software resources designed to complement clinical reasoning might be asset in helping them in this task. AIMS: The goals of this study were to identify the resources third year medical students use to solve a challenging diagnostic case, and specifically to evaluate the usefulness of Isabel, a second-generation electronic diagnosis support system. METHODS: Third year medical students (n = 117) were presented a challenging case and asked to identify and prioritize their top 3 diagnoses, report the time devoted to the exercise, and list the resources they used and their relative usefulness. Students were randomized to receive (or not) free access, instruction, and encouragement to use to a web-based decision support system (Isabel). RESULTS: Students who identified the correct diagnosis as their first choice spent significantly more time on the case than did the other students (3.75 +/- 0.28 hours vs 2.88 +/- 0.15 hours, p < 0.05). Students used electronic resources extensively, in particular Google. Students who self-reported use of Isabel had greater success identifying the correct diagnosis (24/33 = 73% for users vs 45/84 = 53% for non-users) a difference of borderline statistical significance. CONCLUSIONS: These findings indicate that medical trainees use a wide range of electronic decision support products to solve challenging cases. Medical education needs to adapt to this reality, and address the need to teach future clinicians how to use these tools to advantage.