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© Georg Thieme Verlag KG Stuttgart · New York.OBJECTIVE  The aim of this study is to define data model requirements supporting the development of a digital cognitive aid (CA) for intraoperative crisis management in anesthesia, including medical emergency text modules (text elements) and branches or loops within emergency instructions (control structures) as well as their properties, data types, and value ranges. METHODS  The analysis process comprised three steps reviewing the structure of paper-based CAs to identify common text elements and control structures, identifying requirements derived from content, design, and purpose of a digital CA, and validating requirements by loading exemplary emergency checklist data into the resulting prototype data model. RESULTS  The analysis of paper-based CAs identified 19 general text elements and two control structures. Aggregating these elements and analyzing the content, design and purpose of a digital CA revealed 20 relevant data model requirements. These included checklist tags to enable different search optionata models for CAs in other medical domains. Georg Thieme Verlag KG Stuttgart · New York.BACKGROUND  Implementation of disease-specific order sets has improved compliance with standards of care for a variety of diseases. Evidence of the impact admission order sets can have on care is limited. OBJECTIVE  The main purpose of this article is to evaluate the impact of changes made to an electronic critical care admission order set on provider prescribing patterns and clinical outcomes. METHODS  A retrospective, observational before-and-after exploratory study was performed on adult patients admitted to the medical intensive care unit using the Inpatient Critical Care Admission Order Set. The primary outcome measure was the percentage change in the number of orders for scheduled acetaminophen, a histamine-2 receptor antagonist (H2RA), and lactated ringers at admission before implementation of the revised order set compared with after implementation. Secondary outcomes assessed clinical impact of changes made to the order set. RESULTS  The addition of a different dosing strategy for a medication already available on the order set (scheduled acetaminophen vs. as needed acetaminophen) had no impact on physician prescribing (0 vs. 0%, p = 1.000). The addition of a new medication class (an H2RA) to the order set significantly increased the number of patients prescribed an H2RA for stress ulcer prophylaxis (0 vs. 20%, p  less then  0.001). Rearranging the list of maintenance intravenous fluids to make lactated ringers the first fluid option in place of normal saline significantly decreased the number of orders for lactated ringers (17 vs. 4%, p = 0.005). The order set changes had no significant impact on clinical outcomes such as incidence of transaminitis, gastrointestinal bleed, and acute kidney injury. CONCLUSION  Making changes to an admission order set can impact provider prescribing patterns. The type of change made to the order set, in addition to the specific medication changed, may have an effect on how influential the changes are on prescribing patterns. Georg Thieme Verlag KG Stuttgart · New York.BACKGROUND A novel fork-tip fine-needle biopsy (FNB) needle has recently been introduced for endoscopic ultrasound (EUS)-guided sampling. The aim of this study was to compare the performance of fork-tip FNB histology and standard fine-needle aspiration (FNA) cytology in the diagnosis of solid pancreatic masses. METHODS A randomized crossover study was performed in patients referred for EUS-guided sampling. Three passes were taken with each needle in a randomized order. Only samples reported as diagnostic of malignancy were considered positive. The primary end point was the sensitivity of diagnosis of malignancy. Secondary end points included the amount of sample obtained, ease of diagnosis, duration of tissue sampling, pathologist viewing time, and cost. RESULTS 108 patients were recruited. Median age was 69 years (range 30 - 87) and 57 were male; 85.2 % had a final diagnosis of malignancy. There were statistically significant differences in sensitivity (82 % [95 % confidence interval (CI) 72 % to 89 %] vs. 71 % [95 %CI 60 % to 80 %]), accuracy (84 % [95 %CI 76 % to 91 %] vs. 75 % [95 %CI 66 % to 83 %]), proportion graded as a straightforward diagnosis (69 % [95 %CI 60 % to 78 %] vs. 51 % [95 %CI 41 % to 61 %]), and median pathology viewing time (188 vs. 332 seconds) (P  less then  0.001) between FNB and FNA needles, respectively. There was no significant difference in cost between an FNB or FNA strategy. CONCLUSION The diagnostic performance of the fork-tip FNB needle was significantly better than that of FNA; it was associated with ease of diagnosis, shorter pathological viewing times, and was cost neutral. learn more Owner and Copyright ©.BACKGROUND  The indications for endoscopic dissection have been expanded to improve the quality of life of patients with early gastric cancer (EGC). This study aimed to develop a nomogram to predict the status of lymph node metastasis with the aim of avoiding unnecessary gastrectomies. METHODS  We reviewed the clinicopathological data of 10 579 patients who underwent curative resection for EGC. The nomogram was developed by multivariate analysis and was evaluated by external validation. Overall, disease-free and recurrence-free survival were compared between the gastrectomy group of 6641 patients and the endoscopic dissection group of 999 patients to show the efficacy of the nomogram. RESULTS  Multivariate analyses revealed that age, tumor size, lymphatic invasion, depth of invasion, and histologic differentiation were all significant prognostic factors for lymph node metastasis. The nomogram had good discriminatory performance, with a concordance index of 0.846. This was supported by the external validation point of 0.813. For patients with low risk of lymph node metastasis on the nomogram (≤ 3 % of the provisional value in this study), the endoscopic dissection and gastrectomy groups had comparable rates of overall (P = 0.32), disease-free (P = 0.47), and recurrence-free (P = 0.09) survival. CONCLUSIONS  We developed and validated a nomogram that predicts the risk of lymph node metastasis in EGC based on a large database. This precision nomogram is useful to avoid unnecessary gastrectomy after endoscopic dissection, which may ultimately improve the quality of life of patients with EGC. © Georg Thieme Verlag KG Stuttgart · New York.
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