Clinical decision making on the use of physical restraint in intensive care units

Physical restraint is a common nursing intervention in intensive care units and nurses often use it to ensure patients'safety and to prevent unexpected accidents.However,existing literature indicated that the use of physical restraint is a complex one because of inadequate rationales,the negative physical and emotional effects on patients,but the lack of perceived alternatives.This paper is aimed to interpret the clinical decision-making theories related to the use of physical restraint in intensive care units in order to facilitate our understanding on the use of physical restraint and to evaluate the quality of decisions made by nurses.By reviewing the literature,intuition and heuristics are the main decision-making strategies related to the use of physical restraint in intensive care units because the rapid and reflexive nature of intuition and heuristics allow nurses to have a rapid response to urgent and emergent cases.However,it is problematic if nurses simply count their decision-making on experience rather than incorporate research evidence into clinical practice because of inadequate evidence to support the use of physical restraint.Besides that,such a rapid response may lead nurses to make decisions without adequate assessment and thinking and therefore biases and errors may be generated.Therefore,despite the importance of intuition and heuristics in decision-making in acute settings on the use of physical restraint,it is recommended that nurses should incorporate research evidence with their experience to make decisions and adequate assessment before implementing physical restraint is also necessary.

The concept of narrative evidence-based medicine and shared decision-making in traditional Chinese medical practice

For the explosive development of emerging diagnostic and therapeutic technologies brought by the advancement of precision medicine strategy, shared decision-making could improve the quality of clinical decision-making and promote the transformation of clinical research evidence in TCM. Paying attention to patients＇ narrative needs and strengthening medical humanistic concerns could improve clinical outcome and patient satisfaction. We described the origins and development of evidence-based medicine, narrative medicine and shared decision-making, and analyzed the existing problems in TCM clinical decision-making. Further, we put forward the model of shared decision-making between clinicians and patients under the guidance of narrative evidence-based medicine concepts and methods.

The Impact of Simulation Education on Self-Efficacy in Pre-Registration Nursing Students

This literature review primarily aims to explore and synthesise the previous studies in simulation education research conducted over the past five years related to the effects of simulation training on the self-efficacy of undergraduate pre-registration nursing students. The second aim of this study is to explore additional outcome variables that were examined in the previous studies. Five electronic databases were searched systematically. These databases were MEDLINE, CINAHL Plus, Scopus, Embase and PsycINFO. The PICO model was employed to identify the search terms, with a thesaurus being used to provide synonyms. Reference lists of relevant articles were examined and hand searches of journals were also undertaken. The quality of each study was assessed using the Simulation Research Rubric (SRR). A total of 11 studies were included. All studies explored the impact of simulation education on undergraduate pre-registration nursing. Six studies explored nursing students’ competence and performance and two papers examined their critical thinking. Problem solving, learning motivation, communication skills and knowledge acquisition were examined once. The majority of studies indicated that simulation training has a positive impact on pre-registration nursing students’ self-efficacy and other outcome variables. Furthermore, the study results indicate that simulation training is more dependable than traditional training, and students were extremely satisfied with the simulation training. However, most of the studies included in this review had several gaps, including study design, sample size and dissimilarities between the scales used. Further research with large samples, reliable and valid instruments, and outcomes measures (such as critical thinking and transferability of skills) is required to provide better insight into the effectiveness of simulation in undergraduate nursing education. .

Clinical decision-making by the emergency department resident physicians for critically ill patients

The application of main methodologies for clinical decision-making by residents in emergency medical practice was assessed,and issues in this area were investigated.The treatments provided to 2611 critical patients by the Emergency Department of Peking Union Medical College Hospital were analyzed by independent investigators who evaluated the main clinical decision-making processes applied by the hospital residents.The application of decision-making strategies by PG1 and PG3 groups,which means the residents in first year and the third year,were compared.The patients were treated according to pattern recognition(43.0%),hypotheticodeductive reasoning(23.4%),event-driven models(19.3%),and rule-using algorithms(5.9%).A significant difference was found between PG1 and PG3 groups(χ^(2)=498.01,P<0.001).Pattern recognition and hypotheticdeductive methods were the most common techniques applied by emergency physicians in evaluating critically ill patients.The decision-making processes applied by junior and senior residents were significantly different,although neither group adequately applied rule-using algorithms.Inclusion of clinical decision-making in medical curricula is needed to improve decision-making in critical care.

Three Basic Modes for Patients' Clinical Decision-Making in China

In China,there are three basic clinical decision-making modes for patients,namely patients autonomous decision-making mode,family decision-making mode and patient and family codetermination.They were produced under the unique background of Chinese medicine,Confucian philosophy and law in China,l this paper,the concepts,advantages and disadvantages of these three decision-making modes were analyzed In addition,some suggestions were put forward for the improvement.The first is that we suggest to establis standards for choosing decision-making modes;the second is to further learn and publicize relevant laws;thirdly the legal system needs to be further refined;and the last one is to carry out ethical ward round.

规范化培训护士评判性思维与护理临床决策能力的相关性研究

目的:探讨规范化培训护士评判性思维与护理临床决策能力的关系。方法:利用评判性思维态度倾向性调查表—中文版和护理专业临床决策能力测评工具调查130名规范化培训护士。结果:规范化培训护士评判性思维能力总平均分为242.14±20.70分,护理临床决策能力总平均分为73.88±6.13;评判性思维中开放思想与确定目标能力、决断方案能力、能力总分成正相关,系统能力与实施决策能力,求知欲与评价反馈能力呈正相关(P<0.01至0.05)。结论:规范化培训护士护理临床决策能力多数合格水平。规范化护士护理临床决策能力受多种因素影响,培训部门在制定规范化护士培训课程时应重视临床决策能力的培养。

Are there new approaches for diagnosis, therapy guidance and outcome prediction of sepsis?

Beside many efforts to improve outcome, sepsis is still one of the most frequent causes of death in critically ill patients. It is the most common condition with high mortality in intensive care units. The complexity of the septic syndrome comprises immunological aspects- i.e.,sepsis induced immunosuppression- but is not restricted to this fact in modern concepts. So far, exact mechanisms and variables determining outcome and mortality stay unclear. Since there is no typical risk profile, early diagnosis and risk stratification remain difficult, which hinders rapid and effective treatment initiation. Due to the heterogeneous nature of sepsis, potential therapy options should be adapted to the individual. Biomarkers like C-reactive protein and procalcitonin are routinely used as complementary tools in clinical decision-making. Beyond the acute phase proteins, a wide bunch of promising substances and non-laboratory tools with potential diagnostic and prognostic value is under intensive investigation. So far, clinical decision just based on biomarker assessment is not yet feasible. However, biomarkers should be considered as a complementary approach.

A comparison of perspectives on costs in emergency care among emergency department patients and residents

BACKGROUND: Costs of care are increasingly important in healthcare policy and, more recently, in clinical care in the emergency department(ED). We compare ED resident and patient perspectives surrounding costs in emergency care.METHODS: We conducted a mixed methods study using surveys and qualitative interviews at a single, academic ED in the United States. The two study populations were a convenience sample of adult ED patients(>17 years of age) and ED residents training at the same institution. Participants answered open- and closed-ended questions on costs, medical decision making, cost-related compliance, and communication about costs. Closed-ended data were tabulated and described using standard statistics while open-ended responses were analyzed using grounded theory.RESULTS: Thirty ED patients and 24 ED residents participated in the study. Both patients and residents generally did not have knowledge of medical costs. Patients were comfortable discussing costs while residents were less comfortable. Residents agreed that doctors should consider costs when making medical decisions whereas patients somewhat disagreed. Additionally, residents generally took costs into consideration during clinical decision-making, yet nearly all residents agreed that they had too little education on costs.CONCLUSION: There were several notable differences in ED patient and resident perspectives on costs in this U.S. sample. While patients somewhat disagree that cost should factor into decision making, generally they are comfortable discussing costs yet report having insuf? cient knowledge of what care costs. Conversely, ED residents view costs as important and agree that cost should factor into decision making but lack education on what emergency care costs.

Physicians’ Use of Patients’ Daily Reports of Quality of Life to Evaluate Treatment Response in Phase I Cancer Trials

For cancer patients on Phase I trials, one of the most important physician decisions is whether or not patients are deriving benefit from therapy. With an increasing number of cytostatic treatment agents, the criteria to determine patient response to Phase I treatment has become harder to define. Physicians are increasingly looking to patient-reported outcomes (PROs) such as quality of life (QOL) to help evaluate treatment response. Electronic daily diary (EDD) devices can be used by patients to report their QOL over extended periods of time, thereby providing a more accurate picture of how patients are affected by treatment on a daily basis. However, questions remain about how to integrate this patient-reported information into decisions about Phase I treatment. This study investigated how physicians use patients’ daily QOL reports to evaluate patient response to Phase I treatment. Data were collected over a 4-month period from Phase I patients (N = 30) and physicians (N = 3) in an NCI-designated comprehensive cancer center. Patients completed daily QOL reports using EDD devices and physicians were provided with a summary of patients’ QOL before each visit. After the visit, doctors recorded their treatment decision and also rated the importance of four biomedical factors (Toxicity, Imaging, Labs, and Performance Status) and QOL in their treatment decision for that visit. Although physicians rated QOL as being very important in evaluating treatment response, in practice, when predictors of their decisions were analyzed, results showed they relied exclusively on biomedical data (Toxicity, Imaging) to make Phase I treatment decisions. Questions remain about the utility and effective integration of QOL and biomedical data in clinical decision-making processes in Phase I clinical trials.

Patient decision aids for cardiovascular disease： the status-quo and prospects

This article introduced the development and application of patient decision aid （PtDA） for cardiovascular disease. There are many risk factors for cardiovascular disease, and the mortality rate is high. Therefore, continuous management in symptoms, risk factors and lifestyle behaviors is needed for a good prognosis. PtDA can improve the patient＇s understanding of cardiovascular disease and the potential risk of perception of cardiovascular disease, as well as improve the communication between doctors and patients. The emergence of narrative evidence-based medicine provided a new opportunity for the further development of PtDA. At present, there were demands for domestic cardiovascular decision aids, but the researches were extremely limited.

Impact of recipient functional status on 1-year liver transplant outcomes

BACKGROUND The Karnofsky Performance Status(KPS)scale has been widely validated for clinical practice for over 60 years.AIM To examine the extent to which poor pre-transplant functional status,assessed using the KPS scale,is associated with increased risk of mortality and/or graft failure at 1-year post-transplantation.METHODS This study included 38278 United States adults who underwent first,non-urgent,liver-only transplantation from 2005 to 2014(Scientific Registry of Transplant Recipients).Functional impairment/disability was categorized as severe,moderate,or none/normal.Analyses were conducted using multivariableadjusted Cox survival regression models.RESULTS The median age was 56 years,31%were women,median pre-transplant Model for End-Stage for Liver Disease score was 18.Functional impairment was present in 70%;one-quarter of the sample was severely disabled.After controlling for key recipient and donor factors,moderately and severely disabled patients had a 1-year mortality rate of 1.32[confidence interval(CI):1.21-1.44]and 1.73(95%CI:1.56-1.91)compared to patients with no impairment,respectively.Subjects with moderate and severe disability also had a multivariable-adjusted 1-year graft failure rate of 1.13(CI:1.02-1.24)and 1.16(CI:1.02-1.31),respectively.CONCLUSION Pre-transplant functional status is a useful prognostic indicator for 1-year posttransplant patient and graft survival.

Primary hepatic neuroendocrine neoplasm diagnosed by somatostatin receptor scintigraphy:A case report

BACKGROUND Primary hepatic neuroendocrine neoplasm(NEN)is a rare condition,and it is difficult to differentiate between primary and metastatic hepatic NENs.Herein,we report a case of primary hepatic NEN that initially mimicked a hemangioma but showed a gradual increase in size on long-term careful observation.CASE SUMMARY A 47-year-old woman was incidentally diagnosed with a 12-mm liver mass,suspected to be a hemangioma.Since then,regular follow-up had been carried out.Ten years later,she was referred to our institute due to the tumor(located in segment 4)having increased to 20 mm.Several imaging studies depicted no apparent extrahepatic lesion.Positron emission tomography(PET)/computed tomography exhibited significant accumulation in the mass lesion,which made us consider the possibility of malignancy.Left hepatectomy was performed.The histopathological diagnosis was neuroendocrine tumor grade 2,with somatostatin receptor 2 a/5 positivity.Postoperative somatostatin receptor scintigraphy(SRS)showed no other site,leading to the diagnosis of NEN of primary hepatic origin.The gradual growth of the hepatic NEN over 10 years suggested that it was likely to be a primary liver tumor.CONCLUSION In this case,positivity on PET and postoperative SRS may have helped determine whether the tumor was primary or metastatic.

Vigilance in Nurses Working in Intensive Care Units

Background and Aim: Vigilance is an essential element in intensive care nursing. This study was conducted to determine nursing vigilance in nurses working in the intensive care units of educational and medical centers in Ardabil, Iran. Methods: This was a cross-sectional descriptive-analytical study with 192 ICU nurses as the participants. The data were obtained through questionnaires regarding demographic characteristics and nursing vigilance. SPSS software version 24 was used for the statistical analysis. Results: The mean total vigilance score was 3.86 ± 0.23 of 5. The mean scores of the timely diagnosis of changes, pattern recognition, and clinical decision-making subscales were 4.07 ± 0.26, 04.04 ± 0.41, and 3.44 ± 0.25, respectively. No significant relationships were observed between the total or subscale vigilance scores and other demographic characteristics. Conclusion: We assessed ICU nurses’ vigilance behaviors and found that their mean vigilance score was higher than the expected average, indicating our participants had a high level of clinical vigilance. These results suggest a need for effective educational interventions to boost clinical decision-making skills in ICU nurses, especially younger nurses.

Domain knowledge enhanced deep learning for electrocardiogram arrhythmia classification

Deep learning provides an effective way for automatic classification of cardiac arrhythmias,but in clinical decisionmaking,pure data-driven methods working as black-boxes may lead to unsatisfactory results.A promising solution is combining domain knowledge with deep learning.This paper develops a flexible and extensible framework for integrating domain knowledge with a deep neural network.The model consists of a deep neural network to capture the statistical pattern between input data and the ground-truth label,and a knowledge module to guarantee consistency with the domain knowledge.These two components are trained interactively to bring the best of both worlds.The experiments show that the domain knowledge is valuable in refining the neural network prediction and thus improves accuracy.

A novel method to rapidly calculate the urea clearance index and urea reduction rate based on parameters obtained during hemodialysis

Background: The efficacy of hemodialysis (HD) is closely associated with patient survival time and quality of life. The classical method (CLM) to calculate the urea clearance index (Kt/V) and urea reduction rate (URR) requires multiple blood tests. A novel method that may be used as a noninvasive alternative to CLM is required.Methods: Based on the urea kinetic model, a new method, named the "assessment method" (ASM), was established to calculate blood urea nitrogen after HD, based on parameters obtained during HD. The consistency of the Kt/V and URR values between the ASM and CLM was evaluated in 41 patients from the China-Japan Friendship Hospital between September 2017 and December 2018.Results: Forty-one patients (24 males and 17 females;mean age, 55.7 ± 14.2 years) undergoing regular HD in our hospital were randomly selected for this study. The blood flow rate was 244.5 ± 19.6 mL/min and the dialysate flow rate was 500 mL/min. We obtained Kt/V (CLM = 1.40 ± 0.06, ASM = 1.37 ± 0.07) and URR (CLM = 68.6 ± 6.4%, ASM = 67.7 ± 7.2%) values. Pairedt-test indicated no significant differences between the ASM- and CLM-derived values. The intraclass correlation coefficients were 0.907 and 0.916 for Kt/V and URR, respectively. Similarly, Bland-Altman plots suggested good concordance between the 2 methods.Conclusions: The Kt/V and URR values calculated using the ASM and CLM were in significant agreement, and both can be used to effectively assess the adequacy of HD in patients undergoing maintenance HD. The ASM is an effective, rapid, inexpensive, and noninvasive alternative to the CLM for obtaining Kt/V and URR values. The ASM has good potential for clinical application, particularly for patients in areas of low socioeconomic status.

USEVis:Visual analytics of attention-based neural embedding in information retrieval

Neural attention-based encoders,which effectively attend sentence tokens to their associated context without being restricted by long-term distance or dependency,have demonstrated outstanding performance in embedding sentences into meaningful representations(embeddings).The Universal Sentence Encoder(USE)is one of the most well-recognized deep neural network(DNN)based solutions,which is facilitated with an attention-driven transformer architecture and has been pre-trained on a large number of sentences from the Internet.Besides the fact that USE has been widely used in many downstream applications,including information retrieval(IR),interpreting its complicated internal working mechanism remains challenging.In this work,we present a visual analytics solution towards addressing this challenge.Specifically,focused on semantics and syntactics(concepts and relations)that are critical to domain clinical IR,we designed and developed a visual analytics system,i.e.,USEVis.The system investigates the power of USE in effectively extracting sentences’semantics and syntactics through exploring and interpreting how linguistic properties are captured by attentions.Furthermore,by thoroughly examining and comparing the inherent patterns of these attentions,we are able to exploit attentions to retrieve sentences/documents that have similar semantics or are closely related to a given clinical problem in IR.By collaborating with domain experts,we demonstrate use cases with inspiring findings to validate the contribution of our work and the effectiveness of our system.