Development and Implementation of Clinical Decision Algorithms for Oncology.

Decision-making in healthcare often relies on narrative guidelines; however, these instruments are poorly accessible for supporting clinical decision-making. This study explores the application of rule-based decision logic in algorithmic modeling, emphasizing its great potential in clinical decision support and research. Integrating rule-based algorithms with existing information systems and real-world data poses a serious challenge. Integrating decision algorithms with information standards increases their effectiveness across various applications. This study outlines a method for constructing clinical decision trees (CDTs), highlighting their transparency and interpretability, using information standards as a design principle. We use the digitization of the Dutch breast cancer guideline through CDTs as a case study to exemplify their versatility and practical significance. The process step 'primary treatment' has been successfully translated from the narrative guidelines format to the anticipated ted computational format.

Development and Implementation of Standardized, Structured Clinical Reporting for Oncology.

Reuse of clinical data within the healthcare process and for secondary purposes is particularly valuable. This study emphasizes the crucial role of Standardized, Structured Reports (SSRs) in supporting continuity of care while also advancing reusability of data, decision support functionalities, and accommodating future developments. Integrating SSRs with existing information systems poses a serious challenge. The integration of SSRs with information standards enhances their utility in diverse applications. The significance of SSRs is further highlighted by their seamless integration into healthcare processes, and development and implementation is supported by various available applications. This research contributes to the evolution of medical informatics by emphasizing the importance of collaborative efforts in standardized, structured reporting, all aimed at enhancing patient care.

Development and Implementation of Semantic Information Standards for Oncology.

Data exchange in oncological healthcare is hindered by insufficient standardization agreements. An Information Standard comprises agreements facilitating accurate communication of care information with the necessary quality and timeliness. We introduce a structured approach to designing, implementing, and maintaining semantic information standards for oncology, supporting information use across medical scenarios. It consists of an element dataset organized into three tiers, ensuring comprehensive documentation and reliable information exchange. These agreements enhance health data interoperability and system functionality, governed by semantic standardization. Together with communication standards, they empower healthcare professionals with extensive medical records and grant patients control over their health data. Consequently, a high-quality semantic information standard supports both providers and patients, and is adequate during development and manageable during maintenance.

Towards a Learning Health System for Symptom Management in Hospice Care.

The reuse of real-world symptom monitoring data is essential in improving the quality of hospice care. A framework for achieving this is a Learning Health System, in which the development of a well-defined dataset is essential. This paper discusses the challenges in the design of a comprehensive dataset, focusing on variations in two electronic health record systems and divergent care processes.

A novel method for continuous measurements of clinical practice guideline adherence.

Introduction: Clinical practice guidelines (hereafter 'guidelines') are crucial in providing evidence-based recommendations for physicians and multidisciplinary teams to make informed decisions regarding diagnostics and treatment in various diseases, including cancer. While guideline implementation has been shown to reduce (unwanted) variability and improve outcome of care, monitoring of adherence to guidelines remains challenging. Real-world data collected from cancer registries can provide a continuous source for monitoring adherence levels. In this work, we describe a novel structured approach to guideline evaluation using real-world data that enables continuous monitoring. This method was applied to endometrial cancer patients in the Netherlands and implemented through a prototype web-based dashboard that enables interactive usage and supports various analyses. Method: The guideline under study was parsed into clinical decision trees (CDTs) and an information standard was drawn up. A dataset from the Netherlands Cancer Registry (NCR) was used and data items from both instruments were mapped. By comparing guideline recommendations with real-world data an adherence classification was determined. The developed prototype can be used to identify and prioritize potential topics for guideline updates. Results: CDTs revealed 68 data items for recording in an information standard. Thirty-two data items from the NCR were mapped onto information standard data items. Four CDTs could sufficiently be populated with NCR data. Conclusion: The developed methodology can evaluate a guideline to identify potential improvements in recommendations and the success of the implementation strategy. In addition, it is able to identify patient and disease characteristics that influence decision-making in clinical practice. The method supports a cyclical process of developing, implementing and evaluating guidelines and can be scaled to other diseases and settings. It contributes to a learning healthcare cycle that integrates real-world data with external knowledge.

Guideline-Based Algorithmic Recommendations Versus Multidisciplinary Team Advice for Gynecologic Oncology.

Evidence-based clinical decision making in oncology is challenging. Multi-disciplinary team (MDTs) meetings are organized to consider different diagnostic and treatment options. MDT advice are often based on clinical practice guideline recommendations which can be extensive and ambiguous, making it difficult to implement in clinical practice. To address this issue, guideline-based algorithms have been developed. These are applicable in clinical practice and enable accurate guideline adherence evaluation. This ongoing study aims to determine the optimal decision-making approach for different subpopulations of patients with high-incidence gynecological cancers.

Parietofrontal circuits in goal-oriented behaviour.

Parietal and frontal cortical areas play important roles in the control of goal-oriented behaviour. This review examines how signal processing in the parietal and frontal eye fields is involved in coding and storing space, directing attention and processing the sensorimotor transformation for saccades. After a survey of the functional specialization of these areas in monkeys, we discuss homologous regions in the human brain in terms of topographic organization, storage capacity, target selection, spatial remapping, reference frame transformations and effector specificity. The overall picture suggests that bottom-up sensory, top-down cognitive signals and efferent motor signals are integrated in dynamic sensorimotor maps as part of a functionally flexible parietofrontal network. Neuronal synchronization in these maps may be instrumental in amplifying behaviourally relevant representations and setting up a functional pathway to route information in this parietofrontal circuit.

Modulations in oscillatory activity with amplitude asymmetry can produce cognitively relevant event-related responses.

Event-related responses and oscillatory activity are typically regarded as manifestations of different neural processes. Recent work has nevertheless revealed a mechanism by which slow event-related responses are created as a direct consequence of modulations in brain oscillations with nonsinusoidal properties. It remains unknown if this mechanism applies to cognitively relevant event-related responses. Here, we investigated whether sustained event-related fields (ERFs) measured during working memory maintenance can be explained by modulations in oscillatory power. In particular, we focused on contralateral delayed activity (CDA) typically observed in working memory tasks in which hemifield specific attention is manipulated. Using magnetoencephalography, we observed sustained posterior ERFs following the presentation of the memory target. These ERFs were systematically lateralized with respect to the hemisphere in which the target was presented. A strikingly similar pattern emerged for modulations in alpha (9-13 Hz) power. The alpha power and ERF lateralization were strongly correlated over subjects. Based on a mechanistic argument pertaining to the nonsinusoidal properties of the alpha activity, we conclude that the ERFs modulated by working memory are likely to be directly produced by the modulations in oscillatory alpha activity. Given that posterior alpha activity typically reflects disengagement, we conclude that the CDA is not attributable to an additive process reflecting memory maintenance per se but, rather, is a consequence of how attentional resources are allocated.

Neuronal synchronization in human posterior parietal cortex during reach planning.

Although single-unit studies in monkeys have identified effector-related regions in the posterior parietal cortex (PPC) during saccade and reach planning, the degree of effector specificity of corresponding human regions, as established by recordings of the blood oxygen level-dependent signal, is still under debate. Here, we addressed this issue from a different perspective, by studying the neuronal synchronization of the human PPC during both reach and saccade planning. Using magnetoencephalography (MEG), we recorded ongoing brain activity while subjects performed randomly alternating trials of memory-guided reaches or saccades. Additionally, subjects performed a dissociation task requiring them to plan both a memory-guided saccade and reach to locations in opposing visual hemifields. We examined changes in spectral power of the MEG signal during a 1.5 s memory period in relation to target location (left/right) and effector type (eye/hand). The results show direction-selective synchronization in the 70-90 Hz gamma frequency band, originating from the medial aspect of the PPC, when planning a reaching movement. In contrast, activity in a more central portion of the PPC was synchronized in a lower gamma band (50-60 Hz) when planning the direction of a saccade. Both observations were corroborated in the dissociation task. In the lower frequency bands, we observed sustained alpha-band (8-12 Hz) desynchronization in occipitoparietal regions, but in an effector-unspecific manner. These results suggest that distinct modules in the posterior parietal cortex encode movement goals of different effectors by selective gamma-band activity, compatible with the functional organization of monkey PPC.

Gamma-band activity in human posterior parietal cortex encodes the motor goal during delayed prosaccades and antisaccades.

Although it is well established that parietal cortex is important in processing sensorimotor transformations, less is known about the neuronal dynamics of this process in humans. Using magnetoencephalography, we investigated the dynamics of parietal oscillatory activity during saccade planning in terms of sensory and motor goal processing. In the experiments, a peripheral stimulus was flashed in either the left or right hemifield, followed by a 1.5 s delay period, after which the subject executed a saccade toward (prosaccade) or away from (antisaccade) the stimulus. In response to stimulus presentation, we observed an initial increase in gamma-band power (40-120 Hz) in a region in the posterior parietal cortex contralateral to the direction of the stimulus. This lateralized power enhancement, which was sustained in a more narrow frequency band (85-105 Hz) during the delay period of prosaccades, mapped to the hemisphere contralateral to the direction of the saccade goal during the delay period of antisaccades. These results suggest that neuronal gamma-band synchronization in parietal cortex represents the planned direction of the saccade, not the memorized stimulus location. In the lower-frequency bands, we observed sustained contralateral alpha (7-13 Hz) power suppression after stimulus presentation in parieto-occipital regions. The dynamics of the alpha band was strongly related to the processing of the stimulus and showed only modest selectivity for the goal of the saccade. We conclude that parietal gamma-band synchronization reflects a mechanism to encode the motor goals in the visuomotor processing for saccades.

Behavioral and cortical mechanisms for spatial coding and action planning.

There is considerable evidence that the encoding of intended actions in visual space is represented in dynamic, gaze-centered maps, such that each eye movement requires an internal updating of these representations. Here, we review results from our own experiments on human subjects that test the additional geometric constraints to the dynamic updating of these spatial maps during whole-body motion. Subsequently, we summarize evidence and present new analyses of how these spatial signals may be integrated with motor effector signals in order to generate the appropriate commands for action. Finally, we discuss neuroimaging experiments suggesting that the posterior parietal cortex and the dorsal premotor cortex play selective roles in this process.