Dissertations / Theses on the topic 'Diagnosis – Decision-making'

For cardiac surgical patients, the immediate 2-hour recovery period is distinguished by potentially life-threatening haemodynamic instability. To ensure optimum patient outcomes, nurses of varying levels of experience must make rapid and accurate decisions in response to episodes of haemodynamic instability. Decision complexity, nurses’ characteristics, and environmental characteristics, have each been found to influence nurses' decision making in some form. However, the effect of the interplay between these influences on decision outcomes has not been investigated. The aim of the research reported in this thesis was to explore variability in critical care nurses' haemodynamic decision making as a function of interplay between haemodynamic decision complexity, nurses' experience, and specific environmental characteristics by applying a naturalistic decision making design. Thirty-eight nurses were observed recovering patients in the immediate 2-hour period after cardiac surgery. A follow-up semi-structured interview was conducted. A naturalistic decision making approach was used. An organising framework for the goals of therapy related to maintaining haemodynamic stability after cardiac surgery was developed to assist the observation and analysis of practice. The three goals of therapy were the optimisation of cardiovascular performance, the promotion of haemostasia, and the reestablishment of normothermia. The research was conducted in two phases. Phase One explored issues related to observation as method, and identified emergent themes. Phase Two incorporated findings of Phase 1, investigating the variability in nurses' haemodynamic decision making in relation to the three goals of therapy. The findings showed that patients had a high acuity after cardiac surgery and suffered numerous episodes of haemodynamic instability during the immediate 2-hour recovery period. The quality of nurses' decision making in relation to the three goals of therapy was influenced by the experience of the nurse and social interactions with colleagues. Experienced nurses demonstrated decision making that reflected the ability to recognise subtle changes in haemodynamic cues, integrate complex combinations of cues, and respond rapidly to instability. The quality of inexperienced nurses' decision making varied according to the level and form of decision support as well as the complexity of the task. When assistance was provided by nursing colleagues during the reception and recovery of patients, the characteristics of team decision making were observed. Team decision making in this context was categorised as either integrated or non integrated. Team decision making influenced nurses' emotions and actions and decision making practices. Findings revealed nurses' experience affected interactions with other team members and their perceptions of assuming responsibility for complex patients. Interplay between decision complexity, nurses' experience, and the environment in which decisions were made influenced the quality of nurses' decision making and created an environment of team decision making, which, in turn, influenced nurses' emotional responses and practice outcomes. The observed variability in haemodynamic decision making has implications for nurse education, nursing practice, and system processes regarding patient allocation and clinical supervision.

Conventional imaging techniques for cancer detection have difficulty finding small, deep tumors. Single-detector radiation probes have been developed to search for deep lesions in a patient who has been given a tumor-seeking radiopharmaceutical. These probes perform poorly, however, when the background activity in the patient varies greatly from site to site. We have developed a surgical dual-detector probe that solves the problem of background activity variation, by simultaneously monitoring counts from a region of interest and counts from adjacent normal tissue. A comparison of counts from the detectors can reveal the class of tissue, tumor or normal, in the region of interest. In this dissertation we apply methods from statistical decision theory and derive a suitable comparison of counts to help us decide whether a tumor is present in the region of interest. We use the Hotelling trace criterion with a few assumptions to find a linear discriminant function, which can be reduced to a normalized subtraction of the counts for large background count-rate variations. If area under the ROC curve is our figure of merit, the likelihood ratio is the optimum discriminant. We model likelihood functions of the data given the "tumor" and "no-tumor" hypotheses, and calculate the likelihood ratio. Using a spatial response map of the dual probe, a computer torso phantom, and estimates of activity distribution, we simulate a surgical staging procedure to test the dual probe and the discriminant functions. Results of the simulations show that the dual probe effectively solves the problem of background activity variations when used with any of the discriminant functions derived in this dissertation.

Background: The United Kingdom's lung cancer patients have lower survival than patients in comparable countries. Delays in diagnosis may contribute to this. There are significant socio-demographic variations in the interval between cancer patients first presenting to their general practitioner (GP) and referral, but it is unclear why these exist. Aim: To examine patient and GP characteristics associated with GPs' referral decisions, focusing on patients with symptoms indicative of lung cancer. Methods: Study 1: Systematic literature review considering non-clinical patient, GP and practice characteristics associated with variations in GPs' referral of patients for investigations or to secondary care. Study 2: GP decision making study: a factorial experiment using interactive multimedia vignettes to examine GPs' decisions to refer patients with symptoms indicative of lung cancer, and a survey to examine factors influencing decision making. Results: Study 1: 11,791 titles were screened; 47 were of sufficient quality and relevance for inclusion. There was strong evidence that patients over 75 were less likely to be investigated or referred, and of variations by patient gender. However few higher quality studies examined associations with patient ethnicity and GP or practice characteristics, or considered why socio-demographic variations occurred. Study 2: 227 GPs completed the study. GPs were less likely to investigate older than younger patients, and black patients than white. The survey identified several factors that GPs believe affect their referral decisions (such as patients' lifestyles), some of which may explain the observed differences in GPs' referral decisions. Conclusions: My thesis identified socio-demographic variations in GP decision making that are independent of clinical characteristics (for lung cancer and more widely) and factors that may underlie these. Further research addressing the extent to which these factors contribute to socio-demographic variations, and the development of primary care interventions which address these findings, could reduce delays in lung cancer diagnosis.

Prior to the 1990s, bipolar disorder, a behavioral disorder characterized by severe mood fluctuations, was not considered an suitable diagnosis for children. However, in recent decades, an increase in pediatric bipolar disorder (PBD) diagnosis has occurred in the U.S. The purpose of this study was to explore the perceptions and lived experiences of licensed mental health clinicians regarding their decision-making processes used during assessment and diagnosis of PBD. This phenomenographic study utilized individual, semi-structured interviews to explore the perceptions and lived experiences of 14 licensed clinicians in the Commonwealth of Massachusetts who assess and diagnose PBD. Data were collected with a 7-question face to face interview. Using NVivo 10 software several key phrases and words were identified, coded, and used to locate patterns, themes, and concepts. Data analysis revealed that significant issues related to PBD assessment and diagnosis may exist, including: inconsistencies in assessment/diagnostic processes; reticence to diagnose the disorder; failure to use available assessment instruments; a lack of attention to comorbidities; and trouble differentiating between PBD symptoms and other issues, such as trauma or dysfunctional family dynamics. Given the reluctance of these mental health professionals to diagnose PBD, implications for social change underscore the important role of education, training, and ongoing clinical supervision to help other mental health professionals accurately assess and diagnose PBD. Recommendations emanating from study findings suggest further research on PBD assessment and diagnosis to help professionals develop more effective diagnostic frameworks for clinical training and practice.

Research in decision making has identified the importance of prior knowledge and heuristics on decision making behaviour. These develop with experience in a fashion similar to how domain experts develop specialized knowledge structures and heuristic reasoning patterns. This research is extended to the domain of health and lay decision making in a series of studies characterizing conceptualizations of health and illness, information-seeking strategies, and the impact of medical information on lay decision making. Lay subjects included those with diabetes, heart disease, and no identified ongoing medical diagnosis.
Semi-structured interviews and think aloud methodology were employed. Interviews focused on understanding of health and illness, prior knowledge and beliefs, and decision making. In Study One, subjects were presented with health-related problem scenarios and instructed to think aloud as they reasoned through them to make decisions. In Study Two, subjects (lay and medical) were presented with a telecommunications device and scenarios of data to enter into the system. All data were audiorecorded, transcribed, and analyzed for factors and strategies related to information-seeking and decision making behaviours.
Lay understanding of health and illness was characterized as feeling well and functioning in everyday life. The knowledge used in making decisions was based on experience and socio-cultural tradition. Knowledge about disease was found to be decoupled from decisions to act related to illness. Additional information was sought using four criteria grounded in common experience: accessibility, familiarity, complexity, and credibility. These characteristics influenced interactions between lay people and domain experts, such as health care providers, and with technology designed by experts for lay users.
Both technical and lay people make decisions with incomplete information and uncertain outcomes. For lay people making decisions about health-related issues, this incomplete knowledge is filled in based on everyday life rather than medical and scientific facts.

Diagnostic errors cause significant patient harm and occur among 15 percent of all clinical diagnoses, but research has yet to effectively target, prevent, and mitigate diagnostic errors from occurring. So far, literature has examined how diagnostician decision-makers perform and reach a clinical diagnosis individually. However, the impact of team-based activities on diagnosis is unknown. The purpose of this study is to describe provider perception on how providers come together as a team in order to complete a clinical diagnosis. As a qualitative descriptive study with overtones of grounded theory, 18 semi-structured interviews of medical intensive care unit providers were audio-recorded, transcribed, and coded generating themes of diagnostic teamwork structure and functioning. Diagnostic teams are described using themes of inter-professional and intra-professional teamwork among roles with and without diagnostic team identity. Novel approaches to diagnostic error research, practice implications for current providers, and applications provided for improving education and team training. By providing preliminary insights on the role of teamwork in diagnostic decision-making, this study may assist future studies that improve diagnostic teamwork and prevent diagnostic errors.

This dissertation investigated the use of a variety of multivariate statistical procedures to answer questions regarding the value of a number of medical tests and procedures in the diagnosis of space-occupying liver disease. Also investigated were some aspects of test ordering behavior by physicians. A basic methodology was developed to deal with archival data. A number of methodological problems were addressed. Discriminant function analysis was used to determine which procedures and tests served to provide the best classification of disease entities. Although the results were not spectacular, some variables, including a physical examination variable and a number of laboratory procedures were identified as being important. A more detailed analysis of the role of the laboratory variables was afforded by the use of stepwise logistic regression. In these analyses pairs of disease classifications were compared. Two of the more specific laboratory tests, total bilirubin and alkaline phosphate, entered into the equations to provide a fit to the data. Logistic regression analyses employing patient variables mirrored the results obtained with the discriminant function analyses. Liver-spleen scan indicants were also employed as predictor variables in a series of logistic regression analyses. In general, for a range of comparisons, those indicants cited in the literature as being valuable in discriminating between disease entities entered into the equations. Log-Linear models were used to investigate test ordering behavior. In general, test ordering was independent of department. The sole exception being that of the Gynecology-oncology department which relies heavily on Ultrasound. Log-Linear analyses investigating the use of a number of procedures showed differential use of procedures consistent with what is usually suggested in the medical literature for the combination of different imaging and more specialized procedures. Finally, a set of analyses investigated the ordering of a number of procedures relative to specific disease classifications. This set of analyses suffers, as do a number of the other analyses, from insufficient numbers of cases. However, some indications of differential performance of tests for different disease classifications were evident. Suggestions for further study concentrated on the development of experimental procedures given the results of this study.

The overall aim of the thesis was to study clinical decision making in nursing. This was performed by evaluation of the quality of nurses’ diagnostic statements and comparison of the concordance between nurses and patients’ perceptions of the patients’ nursing needs, as well as patient preferences for participation in clinical decision making. Further, predictors regarding patients’ active participation were investigated.

Quasi-experimental, comparative and cross-sectional descriptive study designs were used to collect data in acute care settings from randomly selected patient records (n = 140), nurse-patient dyads (n = 80), and patients discharged from hospital care (n = 428). Data were gathered using questionnaires and review of patient records.

The quality of nurses’ diagnostic statements improved by the means of education directed to nurses and implementation of new forms for recording supporting nursing care planning (I). Discrepancies were found concerning patients and nurses’ perceptions about what constitutes a problem for the patient as well as the severity and importance of acting on the problem (II). Further, nurses perceived that their patients preferred to be more active in clinical decision making compared with the patients’ own preferences for participation (III). Gender, education, living situation, and occupation were identified as predictors for preferring an active role in clinical decision making (IV).

The conclusions are that the accuracy of diagnostic statements needs to be addressed and validated further through systematic assessment of the patients’ perceptions and preferences concerning the health situation and preferences for participation in clinical decision making. Clinical implications are that nurses need to involve patients in identifying patient problems of relevance for nursing. Further, nurses also need to be aware of patients’ preferences for participation in clinical decision making in order that they can plan care in accordance with patient preferences and allow participation to the degree preferred by the patient.

Patientens delaktighet i kliniskt beslutsfattande i omvårdnad – ett gemensamt ansvar för patienter och sjuksköterskor

Bakgrund

Patienten har, med bas i lagstiftning och förordningar, en stark ställning inom svensk hälso- och sjukvård. Det grundas delvis på en samhällelig uppfattning om betydelsen av patientens delaktighet i såväl planering som genomförande av sin egen vård. I ett etiskt perspektiv har delaktigheten ett värde i sig själv, som en förutsättning för individens autonomi och integritet. Sjuksköterskan identifierar patientens behov och problem i syfte att kunna ge en individuellt anpassad omvårdnad. Sjuksköterskan har ofta djupgående professionell kunskap om patientens omvårdnadsproblem, medan patienten har preferenser och värderingar om vårdens genomförande. Om planeringen av omvårdnaden inte utgår från patientens preferenser så finns det stor risk att patientens perspektiv inte kommer med som bedömningsgrund. En samsyn mellan patient och sjuksköterska om patientens behov av omvårdnad och roll i beslutsfattandet kan öka möjligheten att optimera omvårdnadsinsatserna och främja en hög kvalitet på omvårdnaden. Kunskapen om kliniskt beslutsfattande inom omvårdnad är bristfällig, framförallt med fokus på patientens delaktighet och graden av samsyn mellan patienternas och sjuksköterskornas subjektiva perspektiv.

Syfte

Avhandlingens övergripande syfte var att undersöka kliniskt beslutsfattande inom omvårdnad med speciellt fokus på omvårdnadsdiagnosers kvalitet, patientens delaktighet i beslutsprocessen och överensstämmelsen mellan patienters och sjuksköterskors uppfattningar om behov och problem inom omvårdnad.

Specifika syften för respektive delarbeten var att I) undersöka effekten av utbildning i omvårdnadsdiagnostik riktad till sjuksköterskor och utveckling av journaldokument på omvårdnadsdiagnosers kvalitet; II) beskriva överensstämmelse i patienters och sjuksköterskors bedömningar av förekomst, svårighetsgrad och betydelse av problem inom omvårdnaden; III) beskriva samstämmighet mellan patienters och sjuksköterskors uppfattning om patientens preferenser för delaktighet i kliniskt beslutsfattande i omvårdnaden, samt samstämmighet mellan patienters preferenser och faktiska erfarenhet av delaktighet; och IV) identifiera prediktorer för patienters preferenser att delta i kliniskt beslutsfattande om den egna omvårdnaden.

Material och metod

Studier har genomförts med beskrivande, jämförande och kvasi-experimentell design på avdelningar inom somatisk sjukhusvård. Urvalet består av 140 patientjournaler (studie I), 80 patient-sjuksköterskepar (studie II och III), samt 428 patienter som nyligen blivit utskrivna från somatisk sjukhusvård (studie IV). Data har insamlats genom granskning av innehåll i patientjournaler samt genom enkäter till patienter och sjuksköterskor. Instrumenten CAT-CH-ING och Control Preference Scale har använts tillsammans med frågeformulär som utvecklats specifikt för studien.

Resultat

Delarbete I

Kvaliteten på omvårdnadsdiagnoserna förbättrades signifikant efter att sjuksköterskorna på experimentavdelningen genomgått en utbildning och nya journaldokument hade introducerats. Störst kvarvarande svårigheter var förknippade med hur etiologin i omvårdnadsdiagnosen formulerades. Omvårdnadsdiagnosernas kvalitet förbättrades inte på motsvarande sätt på kontrollavdelningarna.

Delarbete II

Sjuksköterskorna identifierade de omvårdnadsbehov och problem som patienterna uppfattade sig ha med en sensitivitet på 0.53 och ett prediktivt värde på 0.50. Det innebär att patienterna delvis identifierade andra problem än sjuksköterskorna, framför allt var det vanligt inom områdena nutrition, sömn, smärta och känslor/andlighet. Sjuksköterskorna underskattade problemens svårighetsgrad för 47 % av de behov och problem som hade identifierats gemensamt av patienter och sjuksköterskor. En gemensam uppfattning om betydelsen av att få stöd och hjälp med att lösa omvårdnadsproblemet fanns i knappt hälften av fallen.

Delarbete III

En majoritet av sjuksköterskorna uppfattade att patienterna föredrog att vara mer aktiva i det kliniska beslutsfattandet om omvårdnad än vad patienterna själv uppgav. Sammanlagt 61 % av patienterna föredrog en passiv roll i beslutsfattandet medan sjuksköterskorna angav att 24 % ville vara passiva. Preferenser om en aktiv roll i beslutsfattande angavs av 9 % av patienterna medan sjuksköterskorna hade uppfattat att 45 % av patienterna föredrog en aktiv roll. Totalt 71 % av patienterna upplevde att de inte hade varit delaktiga i den utsträckning de själva hade föredragit, 37 % hade varit mer passiva och 34 % mer aktiva. Patienterna uppgav att de intagit en mer passiv roll än vad de hade önskat i samband med behov och problem inom områdena kommunikation, andning och smärta, medan en mer aktiv roll än önskat förekom i samband med behov och problem inom områdena aktivitet och känslor/roller.

Delarbete IV

En majoritet av patienterna i sluten somatisk vård föredrog att inledningsvis under vårdperioden inta en passiv roll i kliniskt beslutsfattande om omvårdnad. Sammanlagt 22 % av patienterna föredrog en aktiv roll. Faktorer som predicerade preferenser för att inta en aktiv roll var kön (Odds ratio [OR] = 1.8), utbildning (OR = 2.2), levnadsförhållanden (OR = 1.8) och sysselsättning, d.v.s. om personen var yrkesarbetande eller pensionär (OR = 2.0). Sannolikheten var 53 % att en pensionerad högutbildad kvinna som levde ensam föredrog att vara aktiv i beslutsfattandet om sin egen omvårdnad. Sannolikheten för att en yrkesarbetande lågutbildad man som levde tillsammans med någon annan föredrog att vara aktiv var 8 %.

Slutsats

Kvaliteten på de omvårdnadsdiagnoser som sjuksköterskan ställer kan förbättras genom utbildning men orsakerna till omvårdnadsproblemet behöver identifieras på ett tydligare sätt. Det fanns en skillnad i hur patienter och sjuksköterskor uppfattade vad som utgjorde ett omvårdnadsbehov eller problem samt problemets svårighetsgrad och betydelse. Sjuksköterskan identifierade 53 % av de omvårdnadsproblem som patienten själv identifierade, samtidigt som sjuksköterskan identifierade andra omvårdnadsproblem som inte patienten uppfattade. Uppfattningarna skiljde sig också åt om vilken roll patienten föredrog att ha i det kliniska beslutsfattande om omvårdnad. Faktorer som kunde predicera patientens preferenser att ha en aktiv roll i kliniskt beslutsfattande var kön, utbildningsnivå, boendesituation och om personen yrkesarbetade eller var pensionär.

En slutsats av den påvisade diskrepansen i uppfattningar är att sjuksköterskor i högre grad behöver involvera patienterna i en diskussion om hälsotillståndet, behovet av omvårdnad och patientens önskan att delta i beslut om sin omvårdnad. Det är nödvändigt för att så långt det är möjligt kunna uppnå en samsyn som grund för planering och genomförande av omvårdnaden. Om sjuksköterskan validerar sina egna bedömningar om behovet av omvårdnad med patienten kan kvaliteten på bedömningarna förbättras. Patientens perspektiv blir en explicit del av beslutsunderlaget vid planering av omvårdnad vilket sannolikt också påverkar omvårdnadens innehåll och därmed även omvårdnadens kvalitet. Det bästa sättet att identifiera det individuella perspektivet är genom en systematisk bedömning i dialog mellan sjuksköterskan och den enskilde patienten. Mötet och dialogen mellan patienten och sjuksköterskan är en förutsättning för en god omvårdnad men är också en central del av själva omvårdnaden.

This study investigated whether a defendant?s history of childhood sexual abuse (CSA) and/or personality disorder (PD) diagnosis affected juror decision-making in a child sexual abuse trial. The personality disorders in the study were borderline personality disorder (BPD) and antisocial personality disorder (APD). Participants were 186 college students who read a summary of the trial and then made various juror decisions. The defendant?s CSA history, alone or combined with PD diagnosis, did not affect guilt ratings or sentence recommendations, indicating that jurors did not automatically assume that a defendant who had been abused as a child was guilty (as an adult) of being an abuser. However, when the defendant had a PD diagnosis, there were higher guilt ratings than when there was no PD diagnosis. PD diagnosis was the best predictor of guilt ratings, suggesting that jurors perceive defendants more negatively if they have borderline or antisocial personality disorder.

The research in this thesis aimed to develop an algorithm to support midwives’ diagnosis of active labour in primiparous women and to compare the effectiveness of the algorithm with standard care in terms of maternal and neonatal outcomes. Four linked studies are presented following the template suggested by the Medical Research Council (MRC 2000) Framework for development and evaluation of randomised controlled trials (RCT) for complex interventions to improve health. Study one Aim: To develop an algorithm for diagnosis of active labour in primiparous women. Methods: An informal telephone survey was conducted with senior midwives to assess the need for a decision support tool for the diagnosis of active labour. A literature review identified the key cues for inclusion in the algorithm which was then drafted. Focus group interviews were conducted with midwives to ascertain the cues used by midwives in diagnosing active labour. Findings: Thirteen midwives took part in focus groups. They described using informational cues which could be separated into two categories: those arising from the woman (Physical signs, Distress and coping, Woman's expectations and Social factors) and those from the institution (Midwifery care, Organisational factors and Justifying actions). Study Two Aim: Preliminary testing of the algorithm Methods: Vignettes and questionnaires were used to test the consistency of midwives’ judgements (inter-rater reliability), the content of the algorithm and its acceptability to midwives (face and content validity). The study was conducted in two stages: the first stage (23 midwives) involved vignettes and questionnaires and the second stage (20 midwives) involved vignettes only. Findings: In the first stage a Kappa score of 0.45 indicated only moderate agreement between midwives using the algorithm. After modifying the algorithm, the Kappa score in stage two was 0.86, indicating a high level of agreement. While the majority of the midwives reported that the algorithm was easy to complete, most were able to identify snags or make suggestions for its improvement. Based on the findings of this study the algorithm was modified and the final version was developed. Study three Aim: To assess the feasibility of carrying out a cluster randomised trial (CRT) of the algorithm, in Scotland. Specifically, to identify maternity units potentially willing to participate in a CRT, to test the implementation strategy for the trial and to collect baseline data to inform the sample size calculation. Methods: A questionnaire and interviews were used. The CRT methods were piloted in two maternity units and the algorithm was used for a three-month period in order to test its acceptability and provide estimates of compliance and consent rates. Results: All maternity units surveyed expressed an interest in the proposed study. Midwives’ compliance with study protocol differed between units, although the consent rate of women was high (89% and 84%). Ultimately, one unit achieved 100% of the required sample and the other 60%. The midwives reported that the algorithm was acceptable and was a useful tool, particularly for teaching inexperienced midwives. Study four Aim: To compare the effectiveness of the algorithm for diagnosis of active labour in primiparous women with standard care in terms of maternal and neonatal outcomes. Method: A cluster randomised trial Participants: Fourteen maternity units in Scotland. Midwives in experimental sites used the algorithm to assist their diagnosis of active labour. Seven experimental units collected data from 1029 women at baseline and 896 post intervention. The seven control units had 1291 women at baseline and 1287 after study implementation. Outcomes: The primary outcome was the percentage use of oxytocin for augmentation of labour. Secondary outcomes were medical interventions in labour, labour admission management, unplanned out of hospital births and clinical outcomes for mothers and babies. Results: There was no significant difference between groups in percentage use of oxytocin for augmentation of labour or for the use of medical interventions in labour. Women in the algorithm group were more likely to be discharged from the labour suite following their first labour assessment and subsequently have more pre-labour admissions. Conclusion The studies presented in this thesis represent the full process of developing and testing a complex healthcare intervention (the algorithm). The final study, a national cluster randomised trial, demonstrated that the use of the algorithm did not result in a reduction in the number of women who received oxytocin for augmentation or the use of medical interventions in labour. The results suggest that misdiagnosis of labour is not the main reason for higher rates of intervention experienced by women admitted to labour wards while not yet in active labour. These studies contribute significantly to the debate on care of women in early labour, the organisation of maternity care and to maternity care research.

Background: Diagnostic imaging plays an expanding and central role in patients' medical care. Radiographer clinical reporting is being increasingly used in patient focused services. There is a paucity of research that has examined radiographer chest X-ray reporting. Aim: To determine the diagnostic accuracy of reporting radiographer chest X-ray (CXR) reporting and the influence that CXR reports have on clinicians' diagnostic decision-making. Method: A quasi-experimental study determined the diagnostic accuracy of a cohort of reporting radiographers in CXR interpretation, using a free-response methodology. The influence of CXR reports on clinicians' diagnostic decision-making was determined with a cohort study. A non-inferiority approach was used, in line with Royal College of Radiologists and College of Radiographers guidance that reporting radiographers must be comparable to consultant radiologists. Results: The diagnostic accuracy of reporting radiographers (RR) was non-inferior to consultant radiologists (CR) for all measures, all p < 0.0001; unweighted JAFROC (RR Figure of Merit [FoM]=0.828, 95%CI 0.808-0.847; CR FoM=0.788, 95%CI 0.766-0.811), weighted JAFROC (RR FoM=0.830, 95%CI 0.811-0.849; CR FoM=0.786, 95%CI 0.764-0.808) and inferred ROC (RR Area Under the Curve [AUC]=0.909, 95%CI 0.887-0.931; CR AUC=0.903, 95%CI 0.882-0.924). No difference was found in the number of CXR reports that produced a correct most likely and/or most serious diagnosis (RR 876 of 1337 cases; CR 810 of 1368; p=0.103). Uncorrected most likely diagnostic confidence (RR 72.5 to 80.2; CR 71.0 to 80.4) and uncorrected most serious diagnostic confidence (RR 34.0 to 41.9; CR 33.5 to 39.2) of reporting radiographer CXR reports was non-inferior to consultant radiologists (p < 0.001). Corrected most likely diagnostic confidence, calculated using the Tsushima methodology, was lower (RR 4.61; CR 5.02) with no apparent difference, but noninferiority was not confirmed (p > 0.05). Conclusion: With appropriate postgraduate education, reporting radiographers are able to interpret chest X-rays at a level comparable to consultant radiologists.

This was a retrospective study analyzing the diagnosis of sepsis, a severe systemic reaction to infection, in the emergency department. Sepsis is one of the leading causes of hospital mortality. Though, despite an increased focus on sepsis awareness in recent years, the rates of sepsis are increasing. Both the root causes and the bodily effects of sepsis are varied which makes screening (the identification of potentially septic patients) and diagnosis (the identification of sepsis by a medical professional) extremely difficult. In the face of this uncertainty, several attempts have been made to formalize the definition of sepsis including the systemic inflammation response syndrome (SIRS) criteria. These well-defined criteria can be used to design screens for identifying septic patients via their electronic health record (EHR), but these alerts tend to not be very selective and as such they produce many false alarms. The aim of this study was to determine how these alerts effect the decision making of physicians in the emergency department in regard sepsis diagnosis. More specifically, the goal was to determine if any of a number of well-known cognitive biases: sequential contrast effects, confirmation bias, and representativeness, could be detected in relation to sepsis diagnosis. Using a retrospective dataset of patients for which SIRS alerts were triggered, a set of behavioral criteria were designed using standard sepsis treatment procedures to determine the physicians’ diagnoses of those patients. The distribution of these diagnoses and the way past alerts were related to the diagnosis rates were analyzed. The patterns found in these analyses were constant with that would be expected in decisions made under the influence the identified biases. Additionally, there was found to be correlation between past alerts and the amount of information physicians use to make diagnoses lending further evidence of this conclusion. These results could be used to help design better alerts in the future or to improve the way medical information is presented to physicians to prevent biases from occurring in sepsis diagnosis.

This study aimed to understand how parents’ experience of titration contributes to the adaptive tasks and coping skills associated with their child’s Attention Deficit/ Hyperactivity Disorder (ADHD) diagnoses. The primary research question asks: How does participation in the stimulant titration and Shared Decision-Making (SDM) process help parents create adaptive tasks and coping skills? The participants included 4 parents who have undergone the titration and SDM process as a part of treatment that addresses their child’s ADHD diagnosis. Analysis was conducted via an adapted grounded theory approach and resulted in 11 themes related to the core emergent theme of titration. Themes that were representative of the titration experience were related to the participant’s source of stress, cognitive appraisal of the ADHD diagnosis, adaptive tasks, coping skills, outcomes, and suggested improvements. The results have important implications for improving the titration process. The results also emphasize how titration has promoted adaptive tasks and coping skills which assisted participants to feel more in control and create a new sense of normalcy regarding their child’s ADHD diagnosis.

Resumo: A redução da dose de radiação ao paciente é aceita em Radiologia Odontológica, com a finalidade de diminuir os riscos associados ao exame radiográfico. Para atingir este objetivo, além do avanço tecnológico ocorrido nas últimas décadas, devemos considerar a importância do Critério de Seleção para o paciente e da prescrição radiográfica na indicação correta do tipo de radiografia necessária para cada um deles. O objetivo deste trabalho foi avaliar a prescrição radiográfica de pacientes atendidos pelo Serviço de Medicina Bucal da Faculdade de Odontologia de Araraquara - UNESP durante o período de 1989 a 1993. Selecionamos 396 prontuários que constituiu a totalidade dos que continham exames radiográficos. Para a análise da prescrição radiográfica, consideramos as informações obtidas da ficha clínica e da interpretação das radiografias, utilizando os Critérios de Seleção e a análise de decisão clínica. Os resultados demonstraram um alto índice de pacientes com prescrição incorreta (44,0%); tendo em 24,7% dos pacientes ocorrido mais de uma radiografia prescrita incorretamente. Com relação ao tipo de técnica com prescrição incorreta, em 31,6% dos pacientes foi realizada a radiografia panorâmica, vindo a seguir a oclusal (28,7%), outro (17,2%) e a associação da panorâmica e oclusal (12,6%). Pacientes portadores de doenças e alterações de tecido mole tiveram a mais alta freqüência de prescrições incorretas, seguidos pelos portadores de doenças das glândulas salivares (13,5%) (incluindo os tumores); outros (10,1%); distúrbios da A.T.M. (9,0%); inflamação e infecção dos maxilares (6,8%); tumores benignos (5,6%) e tumores malignos (5,6%). Em 62,9% dos pacientes, o exame radiográfico contribuiu para o diagnóstico e tratamento. A alta porcentagem de prescrição incorreta encontrada evidencia a necessidade de... (Resumo completo, clicar acesso eletrônico abaixo).
Abstract: The reduction in the exposure rate to the patient is very known in Oral Radiology for reducing the patient risk from radiographic examination.Besides the thecnological advances in last decades, development of Selection Criteria for radiographic examination has also been instrumental in patient dose's reduction. A correct radiographic prescription means the correct radiographic view for each individual patient is used. The purpose of this study was to analyse the radiographic prescription of patients in the Oral Medicine Clinic, at Araraquara Dental School - UNESP, during the period between 1989 and 1993. The sample of this study was all of the files that had any type of radiographic examination (396). For the radiographic prescription we have considered the informations from the files and the radiographic interpretation based on Selection Criteria and clinical decision analysis methods.The results showed a high percentage of patients with incorrect prescription ( 44.0%); 24.7% had at least more than one incorrect prescription.From the radiographic views, the panoramic radiographic was prescribed incorrectly in 31.6% of the patients, following by an occlusal view (28.7%) , others (17.2%) and the association of panoramic and occlusal views (12.6%). The patients with soft tissues diseases have had the highest percentage of incorrect prescription (35.0%), following by salivary gland diseases, including the tumors (13.5%); others (10.1%); TMJ disorders (9.0%); jaw's inflamation and infections (6.8%); benign tumors (5.6%) and malignant tumors (5.6%). The radiographic examination contributed for diagnosis and treatment in 62.9% of the patients.The high percentage of incorrect radiographic prescription shows the importance to develop the guidelines in Oral Medicine.

Research into the psychological effects of reproductive decision-making when an individual has a diagnosis of Marfan syndrome, a genetically inherited and potentially life-threatening condition, is rare and mainly quantitative in nature. In response, this study has investigated the experience of couples’ decisionmaking to have a baby when a woman has been diagnosed with Marfan syndrome. The study was conducted using unstructured interview data, analysed using the qualitative methodology of Interpretative Phenomenological Analysis (IPA). The participants were six couples with a female diagnosis of Marfan syndrome. Five couples with children provided retrospective data and one couple making the decision to have a baby provided live data. Four superordinate themes emerged: her decision is already made; creating an informed decision; finding psychosocial support; existing with the fallout of the decision. The experience of decision-making was complex and multidimensional for the males, females and couples. The women demonstrated a strong drive to have a baby despite the 50/50 odds of having a child with Marfan syndrome, whereas the men described the tension between wanting a child and coping with the potentially life-threatening risks for a woman in pregnancy and childbirth. A compelling account of the couples’ difficulties in exploring their options and assessing the risks with medical professionals emerged. It is argued that this research provides important insights for counselling psychologists and other professionals when working with individuals and couples affected by Marfan syndrome and other genetically inherited conditions at the critical time of coping with reproductive decision-making.

The increasingly high costs of health care in the U.S. have led the general public to search for different medical approaches. Since the 1990's, the use of Complementary and Alternative Medicine (CAM) has radically increased in the U.S. due to its approach to treat physical, mental, and emotional causes of illness. In 2009, the National Health Statistics reported the impact of CAM in the U.S. health care economy, with population expenditures of $14.8 billion out-of-pocket on natural Medicine and $12.4 billion out-of-pocket on visits to CAM providers as a complement to Western Medicine care. CAM interconnects human functions to reach a balanced state, whereas Western Medicine focuses on specialties and body systems. Both Western Medicine and CAM are unlimited sources of knowledge that follow different approaches but that have the common goal of improving patients' well-being. Identifying relationships between Alternative and Western Medicine can open a completely new approach for health care that can increase understanding of human medical conditions, and facilitate the development of new and more cost-effective treatments. However, the abundance and dissimilarity of CAM and Western Medicine data makes knowledge correlation and management an extremely challenging task. The objective of this research is to design the framework for a knowledge management system to organize, store, and manage the abundant data available for Western Medicine and CAM, and to establish key relationships between the two practices for an effective exploration of ideas and possible solutions for medical diagnosis. Three main challenges in the design of the proposed framework are addressed: data acquisition and modeling; data organization, storage and transfer; and information distribution for further generation and sharing of medical knowledge. A framework to relate the diagnosis process in Western Medicine and Traditional Chinese Medicine, as one of the various forms of CAM, is presented based on process-oriented analysis, hierarchical knowledge representation, relational database, and interactive interface for system utilization. The research is demonstrated using a case study on chronic prostatitis, and can be scalable to other medical conditions. The presented system for knowledge management is not intended to provide a definite solution for medical diagnosis, but to enable the exploration and discovery of knowledge for relational medical diagnosis. The results of this research will positively impact information distribution and knowledge generation via interactive medical knowledge systems, development of new skills for diagnosis and treatment, and a broader understanding of medical diseases and treatments.

Clinical risk assessment of chronic illnesses is a challenging and complex task which requires the utilisation of standardised clinical practice guidelines and documentation procedures in order to ensure consistent and efficient patient care. Conventional cardiovascular decision support systems have significant limitations, which include the inflexibility to deal with complex clinical processes, hard-wired rigid architectures based on branching logic and the inability to deal with legacy patient data without significant software engineering work. In light of these challenges, we are proposing a novel ontology and machine learning-driven hybrid clinical decision support framework for cardiovascular preventative care. An ontology-inspired approach provides a foundation for information collection, knowledge acquisition and decision support capabilities and aims to develop context sensitive decision support solutions based on ontology engineering principles. The proposed framework incorporates an ontology-driven clinical risk assessment and recommendation system (ODCRARS) and a Machine Learning Driven Prognostic System (MLDPS), integrated as a complete system to provide a cardiovascular preventative care solution. The proposed clinical decision support framework has been developed under the close supervision of clinical domain experts from both UK and US hospitals and is capable of handling multiple cardiovascular diseases. The proposed framework comprises of two novel key components: (1) ODCRARS (2) MLDPS. The ODCRARS is developed under the close supervision of consultant cardiologists Professor Calum MacRae from Harvard Medical School and Professor Stephen Leslie from Raigmore Hospital in Inverness, UK. The ODCRARS comprises of various components, which include: (a) Ontology-driven intelligent context-aware information collection for conducting patient interviews which are driven through a novel clinical questionnaire ontology. (b) A patient semantic profile, is generated using patient medical records which are collated during patient interviews (conducted through an ontology-driven context aware adaptive information collection component). The semantic transformation of patients’ medical data is carried out through a novel patient semantic profile ontology in order to give patient data an intrinsic meaning and alleviate interoperability issues with third party healthcare systems. (c) Ontology driven clinical decision support comprises of a recommendation ontology and a NICE/Expert driven clinical rules engine. The recommendation ontology is developed using clinical rules provided by the consultant cardiologist from the US hospital. The recommendation ontology utilises the patient semantic profile for lab tests and medication recommendation. A clinical rules engine is developed to implement a cardiac risk assessment mechanism for various cardiovascular conditions. The clinical rules engine is also utilised to control the patient flow within the integrated cardiovascular preventative care solution. The machine learning-driven prognostic system is developed in an iterative manner using state of the art feature selection and machine learning techniques. A prognostic model development process is exploited for the development of MLDPS based on clinical case studies in the cardiovascular domain. An additional clinical case study in the breast cancer domain is also carried out for the development and validation purposes. The prognostic model development process is general enough to handle a variety of healthcare datasets which will enable researchers to develop cost effective and evidence based clinical decision support systems. The proposed clinical decision support framework also provides a learning mechanism based on machine learning techniques. Learning mechanism is provided through exchange of patient data amongst the MLDPS and the ODCRARS. The machine learning-driven prognostic system is validated using Raigmore Hospital's RACPC, heart disease and breast cancer clinical case studies.

Нагорна, Д. А. Система підтримки прийняття рішень для діагностики хвороб серця : випускна кваліфікаційна робота : 121 "Інженерія програмного забезпечення" / Д. А. Нагорна ; керівник роботи І. В. Білоус ; НУ "Чернігівська політехніка", кафедра технологій та програмної інженерії. – Чернігів, 2021. – 68 с.
Запропоновані технічні та експлуатаційні результати роботи Необхідно розробити систему підтримки прийняття рішень для підвищення точності в процесі діагностики захворювань серця. Система повинна забезпечувати наступний функціонал: - отримати дані про пацієнта з аналізами крові та амбулаторною інформацією та під час вводу валідувати їх; - можливість обирати, за допомогою якої моделі машинного навчання виконувати передбачення; -- виконувати прогноз наявності чи відсутності хвороби серця на основі даних від користувача; - надавати особі, яка приймає рішення результат згідно обраної моделі; - формувати результат перевірки, з якою ймовірністю у людини є хвороба серця; - представляти результат особі, що приймає рішення в зручному ВИГЛЯДІ. В результаті роботи повинен формуватися результат з ймовірністю перевірки на наявність серцевої хвороби і довідка про точність, правильність, повноту, специфічність отриманого результату. Необхідно спроектувати і розробити систему, та практично довести доцільність та ефективність запропонованого методу у процесі прийняття рішення.
Proposed technical and operational results It is necessary to develop a decision support system to improve accuracy in the diagnosis of heart disease. The system should provide the following functionality: - obtain patient data with blood tests and outpatient information and validate them during input; - the ability to choose which model of machine learning to make predictions; - predict the presence or absence of heart disease based on user data; - provide the decision-maker with the result according to the chosen model; - to form the result of the test, with what probability a person has heart disease; - present the result to the decision maker in a convenient way APPEARANCES. As a result of work the result with probability of check for existence of heart disease and the certificate on accuracy, correctness, completeness, specificity of the received result should be formed. It is necessary to design and develop a system, and practically prove the feasibility and effectiveness of the proposed method in the adoption process decision.

Background: Diagnosis of acute coronary syndromes (ACS) in the Emergency Department (ED) is a topical and contentious issue. Current diagnostic techniques rely on hospital admission for troponin testing. Only a minority of those admitted prove to have ACS while unacceptable proportions of those discharged have unrecognised ACS. Aims: We aimed to evaluate the diagnostic and prognostic value of individual clinical findings and novel biomarkers in ED patients with suspected cardiac chest pain. We then aimed to derive a clinical decision rule (CDR) to potentially enable safe, immediate discharge of a proportion of patients from the ED while risk stratifying others to facilitate triage to an appropriate level of in-patient care. Methods: We recruited patients who presented to the ED with suspected cardiac chest pain. Variables that have previously been shown to predict diagnosis of acute myocardial infarction (AMI) or to predict outcome were prospectively recorded. Blood was drawn at presentation for levels of eight biomarkers. Patients underwent 12-hour troponin testing and were followed up for the composite primary outcome of AMI, death or urgent coronary revascularisation for six months. Variables that were univariate predictors (p<0.05) of outcome were entered into a multivariate analysis using recursive partitioning. Results: While many clinical findings and levels of all eight novel biomarkers were found to be significant predictors of outcome, none could be used individually to confirm or exclude ACS in the ED. We derived a nine-point CDR that combined clinical findings with biomarker levels to effectively stratify patients into four risk groups. 14.2% of patients were identified as being at ‘no risk’ and had a 0.0% outcome rate. The rule performed significantly better than two commonly used risk scores and may improve on triage decisions made in actual clinical practice. Conclusion: ACS remains a difficult diagnosis to confidently confirm or refute in the ED. Our CDR may help to avoid unnecessary hospital admissions while improving on triage decisions made for the remaining in-patients. Prospective validation of our findings is warranted.

La pile à combustible apparaît comme un système performant pour produire de l’électricité « verte » à partir de l’hydrogène dès lors que celui-ci est produit à partir de sources d’énergie renouvelables. Les avantages et la maturité de la technologie à membrane polymère font des PEMFC des candidates prometteuses. Cependant, plusieurs verrous scientifiques et technologiques limitent encore leur utilisation à grande échelle, en particulier leur coût, leur fiabilité et leur durée de vie. L’amélioration de ces caractéristiques passe par la mise en place d’outils de supervision, de détection de défauts et de contrôle des systèmes pile à combustible (PàC). Le travail de recherche est le fruit d’une collaboration entre le FC LAB de l’Université de Bourgogne Franche Comté et le LE2P de l’Université de La Réunion. Ce sujet de thèse s’inscrit dans la continuité des travaux menés au laboratoire FC LAB, portant en particulier sur le diagnostic et le pronostic de systèmes PàC, et des travaux menés au laboratoire LE2P, portant sur le test en ligne d’algorithmes de commande de PEMFC. Parmi les méthodes développées pour déployer la sureté de fonctionnement à un système physique, on retrouve les techniques de tolérance aux défauts, conçues pour maintenir la stabilité du système ainsi que des performances acceptables, même en présence de défauts. Ces techniques se décomposent généralement en trois phases : la détection d’erreurs ou de défaillances, l’identification des défauts à l’origine des problèmes, et l’atténuation. La littérature fait état d’un grand nombre d’outils de diagnostic et d’algorithmes de contrôle, mais l’association du diagnostic et du contrôle reste marginale. L’objectif de ce travail de thèse est donc le test en ligne de différentes stratégies de commande tolérante aux défauts, permettant de maintenir la stabilité du système et des performances acceptables même en présence de défauts
Fuel cells (FC) are powerful systems for electricity production. They have a good efficiency and do not generate greenhouse gases. This technology involves a lot of scientific fields, which leads to the appearance of strongly inter-dependent parameters. It makes the system particularly hard to control and increase the fault’s occurrence frequency. These two issues underline the necessity to maintain the expected system performance, even in faulty condition. It is a so-called “fault tolerant control” (FTC). The present paper aims to describe the state of the art of FTC applied to the proton exchange membrane fuel cell (PEMFC). The FTC approach is composed of two parts. First, a diagnostic part allows the identification and the isolation of a fault. It requires a good a priori knowledge of all the possible faults in the system. Then, a control part, where an optimal control strategy is needed to find the best operating point or to recover the fault

Background: Unlike other cancers, malignant melanoma (MM) is generally visible and can be easily and effectively cured if treated in time. Optimal cure of MM requires early detection, diagnosis, and treatment, which improves prognosis. However, patients as well as the health care organization and its professionals contribute to delayed treatment in various ways. Aims and objectives: The general aim of this PhD thesis was to explore reasons for delay in care seeking, diagnosis, and treatment of malignant melanoma. The specific objectives to be addressed were To explore patients’ decision making about seeking care for malignant melanoma To identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men To compare self-reported decision making coping styles between men and women in various ages, who live with or without a partner and are diagnosed with various stages of malignant melanoma in northern Sweden. To describe and compare patients diagnosed with MM, depending on their initial contact with care, and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals between clinics from the initial contact to diagnosis and treatment. Methods: In studies I and II, 21 and 30 patients, respectively, were interviewed about their decision making to seek care for MM. Study II focused on gender patterns in this decision making. The interviews were analysed using Grounded Theory (I) and qualitative content analysis (II). Study III included 270 people with MM who completed a translated questionnaire (Melbourne Decision Making Questionnaire) about coping styles in decision making. In study IV the pathways and time delay in health care for 71 people with MM were explored. Studies I and II were qualitative, whereas studies III and IV were quantitative. Results: In study I, the insights into severity and feelings of fear and existential threat were identified as key motivators for patients to decide to seek care for a suspected melanoma. Results in study II showed that gender constructions influenced the care-seeking behaviour. Women acknowledged the skin changes and attempted self-care first. They delayed care seeking due to family responsibilities. Men seldom acknowledged the suspicious skin change, but sought care immediately after prompting, and most often complied with relatives’ advice to seek care. Study III showed that men generally scored higher in buck-passing, while women and those living without a partner scored higher in hypervigilance. Participants with nodular melanoma (NM), a rapid-growing form of MM, scored higher in vigilance than those diagnosed as in situ melanoma. No correlation was found between tumour thickness and coping styles. Some differences concerning treatment of MM were found in study IV between people who initially had sought care at primary health care centres (PHC) and those who had sought care at dermatological and specialist clinics (Derm). Thicker tumours as well as NM were more common in the PHC group. A larger proportion of patients from PHCs were primarily excided within the primary health care; however, almost all of them were later referred to surgical clinics for wide excision. Patients within the PHC group also had to wait longer for the registered results of histopathological assessments. In general, women waited a shorter time for primary excision, and older people waited longer for wide excision. Conclusions: Time delay of diagnosis and treatment of MM is still common, and crucial to decrease. Future interventions should include gender aspects to influence people to seek care earlier. In health care, time delay could be decreased by facilitating access for patients with suspected skin melanomas, but also by reducing unnecessary referrals. Moreover, organizational changes whereby general practitioners and primary health care nurses are supported in using new technology for faster diagnoses and management of MM in collaboration with specialist clinics should be considered. Easy access and frequently used guidelines for MM could further decrease delay. Lastly, more efficient transfer and registration of laboratory results and referrals could decrease delay and improve patient safety.
Bakgrund: Malignt melanom (MM) är till skillnad från andra cancerformer ofta synlig och kan enkelt och kostnadseffektivt botas om det behandlas i tid. En optimal prognos av MM förutsätter tidig upptäckt, diagnos och behandling. Patienter, samt hälso- och sjukvården, dess organisation och dess personal kan på olika sätt bidra till fördröjning av behandlingen av MM. Syfte: Det övergripande syftet med denna avhandling var att undersöka orsaker till fördröjning att söka vård, diagnosticera och behandla malignt melanom. Specifika delsyften var:   Att utforska patienternas beslutsfattande process att söka vård för MM Att identifiera specifika mönster i beslutsfattande-processen att söka vård för misstänkt MM utifrån kvinnors och mäns egna berättelser  Att jämföra självrapporterade coping-stilar i den beslutsfattande processen mellan män och kvinnor i olika åldrar, boende med eller utan partner, och diagnosticerade med MM i olika stadier från norra Sverige Att beskriva och jämföra patienter med MM utifrån deras primära vårdkontakt samt utifrån ålder, kön, MM-typ och tjocklek. Ytterligare att utforska vård- och remissvägar samt tidsintervaller mellan olika kliniker från första kontakt till diagnos och behandling. Metod: I studie I och II, intervjuades 21 respektive 30 patienter om den beslutsfattande processen att söka vård för MM. Genuskonstruktioner i relation till den beslutsfattande processen var i fokus i studie II. Intervjuerna analyserades med hjälp av Grounded Theory (I) och kvalitativ innehållsanalys (II). I studie III inkluderades 270 patienter med MM som besvarade ett instrument (MDMQ) avseende coping-stilar i beslutsfattande processen. I studie IV undersöktes övergångar mellan olika kliniker och remissvägar för 71 patienter med MM samt eventuell tidsfördröjning inom hälso- och sjukvården. Resultat: I studie I, identifierades insikt i allvarlighetsgrad samt rädsla och existentiellt hot till följd av tillståndet vara nyckel-motivatorer för att bestämma sig för att söka vård för misstänkt hudmelanom. Resultat från studie II påvisade att genuskonstruktioner påverkar hur personer söker vård för MM. Kvinnor upptäckte själv sina melanom och försökte tillämpa egenvård i början. De kunde dröja att söka vård pga. ansvar för familjen. Män upptäckte sällan suspekta melanom själva men följde oftast anhörigas råd att söka vård och sökte vård omedelbart efter påstötning. Resultaten från studie III visade att män i högre grad använde en avvaktande startegi (buck-passing) medan kvinnor och de som bodde utan partner var överdrivet vaksamma (hypervigilance). Deltagare med nodulärt melanom (NM), en snabbt växande form av MM, var mer vaksamma (vigilance) jämfört med de med melanom in situ, en mycket tidig form av melanom. Några korrelationer mellan tumörtjocklek och coping-stilar hittades ej. Vissa skillnader avseende typer av MM samt vårdens handläggning beroende på var patienter initialt sökt vård identifierades i studie IV. Bland patienter som initialt sökt vård på hälsocentralerna var tjockare tumörer vanligare jämfört med dem som hade sökt vård på hud- och andra specialistklinker. Dessa patienter hade också som regel genomgått den primära excisionen på hälsocentralerna och en majoritet blev senare remitterade till kirurgisk klinik för utvidgad excision. Hälsocentralernas patienter fick vänta längre på att det histopatologiska svaret registrerades i journalen än sjukhusklinikernas patienter. Kvinnor fick generellt vänta kortare tid på primär excision och äldre patienter fick vänta längre för utvidgad excision. Slutsatser: Tidsfördröjning av diagnos och behandling av MM är fortfarande vanlig och därför viktig att minska. Framtida interventioner för att påverka människor att söka vård tidigare bör inkludera genusaspekter. Inom hälso- och sjukvården kan tidsfördröjning minskas genom förbättrad tillgänglighet för patienter med misstänkta hudmelanom, men också genom minskning av onödig remittering. En förändrad organisation där sjuksköterskor och primärvårdsläkare i samarbete med specialistkliniker stöttas att använda ny teknologi för snabbare diagnosticering och omhändertagande av MM bör övervägas. Ökad kännedom bland hälso- och sjukvårdspersonal om riktlinjer for MM-vård kan vidare minska fördröjning. Till sist, mer effektiva och förbättrade arbetssätt kring registrering och överföring av laboratoriska svar och remisser skulle kunna minska fördröjning och därmed öka patientsäkerheten.

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Made available in DSpace on 2018-05-16T13:56:30Z (GMT). No. of bitstreams: 1 ADRIANO ARAÚJO SANTOS - TESE (PPGCC) 2016.pdf: 2344426 bytes, checksum: a867de6494509fd81bbcae390cd6bed4 (MD5) Previous issue date: 2016
Diariamente, médicos especialistas analisam casos clínicos complexos e devem tomar decisões que podem afetar negativamente o bem estar de seus pacientes, os custos de procedimentos, o preço de seguros de saúde e a reputação dos especialistas e sistemas médicos envolvidos, ou até mesmo, serem fatais. A busca pela melhoria dos procedimentos na área de saúde, principalmente no intuito de mitigar os riscos de eventos adversos, tem se apresentado como um dos grandes desafios da atualidade, e o desenvolvimento de métodos e sistemas computacionais que auxiliam os especialistas no processo de decisão tem sido crescente no meio científico e empresarial. No tocante à presente pesquisa, o objetivo principal foi propor um modelo para auxílio à tomada de decisão em casos clínicos considerando diagnóstico coletivo, com a finalidade de mitigar os riscos e as incertezas enfrentados por especialistas médicos. A fim de avaliar a aplicabilidade de Anaís, dois produtos de software foram desenvolvidos e um experimento envolvendo 75 especialistas de saúde em formação profissional, organizados em 15 grupos, para resolver 15 casos clínicos, foi realizado. Os resultados obtidos foram estatisticamente significativos no que se refere à aplicabilidade do Anaís para o processo de mitigação de erros de decisão e enquanto ferramenta educacional, de acordo com opiniões dos participantes, atingindo, assim, o objetivo proposto na pesquisa.
Day after day, medical specialists analyze complex clinical cases and make decisions that can negatively affect their patients' well-being, procedure costs, health insurance costs, and the reputation of medical experts and systems involved, or even fatal. The search for better procedures in the health area, mainly in order to mitigate the risks of adverse events, has been presented as one of today's great challenges, and the development of computational methods and systems that help decision makers have been growing in the scientific and business environment. With regard to the present research, the main goal was to build a model to aid decision-making in clinical cases considering collective diagnosis. In order to evaluate the applicability of Anaís, two software products were developed and an experiment involving 75 healthcare specialists in professional training, organized in 15 groups to resolve 15 clinical cases were designed. Anaís has obtained statistically significant results of its possible applicability to the process of mitigation of decision errors and as an educational tool, according to the participants' opinions, thus reaching the objective proposed in the research.

Objective: Expanding the original scope of the study, which was to explore the decision-making process of pregnant women in the uptake of invasive diagnostic tests - amniocentesis and Chorionic Villus Sampling (CVS) – and taking into account the latest emergence of a Noninvasive Prenatal Testing, NIPT, the primary goal of this study was to explore factors that influence women’s decision to have an invasive, a non-invasive or no further testing at all. Design and sample: The Prenatal Decision Making Questionnaire (PDMQ) developed for the purposes of this study. Following a pilot test and factor analysis, it was distributed to a population of pregnant women (N=421) prior to them receiving their combined screening results. The total sample was divided into three sub-groups according to their risk status (low-intermediate-high) for the analysis. Results. Logistic regression analysis using the R version 3.0.3 revealed that none of the PDMQ factors had a significant impact on women’s decision to have an invasive test (CVS), whereas the following three factors had a significant impact on the decision to have a non-invasive test (NIPT): negative attitude to doctors and an internal locus of control were associated with the uptake of NIPT, whereas a negative attitude to medicine was associated with rejection of NIPT When risk status was included in the model it was found that uptake of NIPT was predicted by the presence of some level of risk for T21 or T13/T18. On the contrary, uptake of CVS was only predicted by an increased risk for T21. Conclusion(s): Women’s decision making process in prenatal diagnosis is affected by several factors with personalised risk being one of the key determinants. The findings of this study can be used by healthcare professionals in providing the appropriate support and information and facilitating an informed decision during this stage of pregnancy.

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Electrical Engineering and Computer Science, 1998.
Includes bibliographical references (p. [231]-235).
by Mary Jane Boyd.
Ph.D.

The prevalence of medical misdiagnosis has remained high despite the adoption of diagnostic software. This ongoing controversy about the role of technology in mitigating the problem of misdiagnosis centers on the question of whether diagnostic software does reduce the incidence of misdiagnosis if properly relied upon by physicians. The purpose of this quantitative, cross-sectional study based on planned behavior theory was to measure doctors' opinions of diagnostic technology's medical utility. Recruitment e-mails were sent to 3,100 AMA-accredited physicians through their database that yielded a sample of 99 physicians for the study. One-sample t tests and, where appropriate because of non-normal data, one-sample Wilcoxon signed-rank tests were conducted on the data to address the following key research questions on whether diagnostic software decreases misdiagnosis in healthcare versus unassisted human diagnostic method, if physicians use diagnostic software frequently enough to decrease misdiagnosis in healthcare, and if liability concerns prevent physicians from using diagnostic software. It was found that in the opinion of those surveyed (a) diagnostic software was likely to result in fewer misdiagnoses in healthcare than unassisted human diagnostic methods, (b) when speaking for themselves, physicians thought they used diagnostic software frequently enough to decrease misdiagnoses, and (c) physicians agreed they were not prevented from using diagnostic software because of liability concerns. The study's social significance is the affirmation of diagnostic software's usefulness: Policy and technology stakeholders can use this finding to speed the adoption of diagnostic software, leading to a reduction in the socially costly problem of misdiagnosis.

Les maladies les plus fréquentes prédisposant au cancer colorectal sont le Syndrome de Lynch et la Polypose Adénomateuse Familiale. Les gènes du système MMR, le gène APC et le gène MUTYH sont respectivement responsables. Le conseil génétique est primordial pour une prise en charge optimale des patients et des familles. Les Comités d'Oncogénétique aident les professionnels de santé à décider d'une indication d'analyse génétique et au suivi des familles. Nous souhaitons évaluer et améliorer a qualité décision prise pour une famille à risque. Des décisions très disparates d'un cas familial à un autre équivalent ont été suspectées. A Lyon, nous avons créé une base de données pour analyser et contribuer cela. Résultat : 100% (33/33) des centres français de consultations principales d'oncogénétique ont décrit l'organisation de leurs COG: 76% développent un COG spécifique, 24% utilisent une concertation standard. Environ 3.75 spécialités médicales sont rassemblées par COG, dont des oncogénéticiens (100%), gastro-entérologues (76%), conseillers en génétiques (84%), chirurgiens (32%), et biologistes/anatomopathologistes (36%). Vingt pourcent des centres ayant une COG spécifique discutent tous leurs cas familiaux, 80% sélectionnent leurs dossiers. Dans notre région, un outil informatique a été élaboré et sera largement diffusé. Notre but étant de standardiser nos décisions et, catégoriser des groupes de patients/familles, pour standardiser la surveillance proposée chez les familles équivalentes. Une meilleure rationalisation de la prise en charge, du suivi des familles, et de la prévention est ici ciblée
The most common diseases that predispose for colorectal cancers are Lynch Syndrome and Familial Adenomatous Polyposis. The genes of MMR system, the APC gene and the MUTYH gene are respectively responsible. Genetic counselling is imperative for an optimal care making for patients and at-risk families. Multidisciplinary committees (MDC) are organized so as to help healthcare professionals for gene analysis decision and families' follow-up. Our aim is evaluation and improvement of quality decision-making for at-risk families. A disparate distribution of decisions from one familial case to another equivalent one has been suspected and observed. In Lyon region we created a database to analyse that and contribute to harmonize the different participants' work in MDC. Results: the 33 French oncogenetic main consultation centers described the organization of their MDC. Answering rate reached 100%. Among these centers, 76% developed a specific MDC, whereas 24% used standard consultation. About 3.75 different medical specialities are gathered by MDC. Among them, there are oncogeneticists (100%), gastroenterologists (76%), genetic counsellors (84%), surgeons (32%), and biologists (36%). Twenty percent of centers having a specific MDC evaluate all their patient cases, whereas 80% select them. In Lyon region, a computerized tool has been elaborated and will be widely disseminated to every collaborating partners of our MDC. It will enable us to standardize our decision-making and, by comparing decisions through quality criteria, to differentiate and categorize some patients/families groups. A better rationalization of care management, families' follow-up and prevention is targeted

Individuals diagnosed with schizophrenia commonly experience problems with accurately assessing their health status due to cognitive deficits including impaired working memory, amotivation, and communication difficulties. Little is known about whether these deficiencies influence health behavior decision-making among individuals with schizophrenia. Individuals with schizophrenia die an average of 25 years earlier than those without a mental illness. Approximately 60% of premature deaths in this population are from medical comorbidities; mortality rates due to cardiovascular and pulmonary diseases are two to three times higher than the general population. In order to reduce morbidity and mortality, it is important to find effective ways to assist these individuals in modification of risky behaviors (e.g., smoking, poor dietary habits, and sedentary lifestyles) and to incorporate daily health promoting behaviors (e.g., balanced diet and regular exercise). This qualitative descriptive study was conducted to describe the decision-making processes used by adults with schizophrenia when making health behavior decisions, identify what it means to be healthy from the perspectives of adults with schizophrenia, and identify the perceived barriers and facilitators that affect health behavior decisions. Ten adults diagnosed with schizophrenia were interviewed for this study. Fifty-percent of participants were female, ages 28 to 59 years, and received treatment in a community mental health centers. Data were analyzed using content analysis. Methods included the use of field notes, open and axial coding, and development of a visual model. Trustworthiness of the findings was established through the qualifications and experience of the investigator, peer scrutiny, and member checks. Three phases of health behavior decision making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. The main category that described health behavior decision making was “Tracking Health Behaviors,” which resulted in the ability to maintain physical and mental health. Within each phase, specific actions associated with achieving and maintaining physical and mental health were identified and were displayed in a visual model. These findings provide a guide to clinicians in identifying health behavior decision making processes and may lead to the design of clinical interventions that improve the health status of adults with schizophrenia.

Behavior rating scales are commonly used as part of the evaluation process throughout the field of psychology. Behavior rating scales help assess social, emotional, and/or behavioral problems in children, adolescents, and teens. Behavior rating scales indicate the severity of problem behaviors compared to a normative sample. Four scenarios were developed that varied scores on a behavior rating scale and the amount of other information that supported a specific diagnosis. A rating of the likelihood of a diagnosis was requested to see how much influence behavior rating scale scores have on diagnostic decision-making. Each of the four scenarios was sent to 200 school psychologists across the country for a total of 800 potential participants. An overall response rate of 37.5% was achieved. The findings revealed that behavior rating scales do have some influence on school psychologists’ diagnostic decision-making. However, school psychologists put more weight on other supporting information, such as classroom observations and teacher and parent reports, than on behavior rating scale scores when making a diagnostic decision.

Each year millions of people face the medical decision-making cycle that comes with a diagnosis of cancer. For patients and their families, this can be a rollercoaster of confusion and fear. Researchers have indicated that the complexity of the decision-making process is underrepresented in the current approach of informed decision-making. The purpose of this study was to add to scientifically-validated research expanding the identification of factors that influence decision-making for individuals diagnosed with cancer. Fuzzy trace theory (FTT) is the dual process memory theory used as the framework for this study. Qualitative data were collected using semistructured interviews with 10 participants. The sampling strategy included purposeful sampling and snowball or chain sampling. The audio-recorded interviews were transcribed and analyzed. Software tools were used to aid in the creation of word mapping and clusters and a naming structure emerged. A comprehensive thematic analysis was completed. Participants detailed experiences with family and social dynamics, psychological or emotional stress, external influencing factors to the decision-making process, and experiences with cancer advertising. This research can create positive social change through the advancement of scientifically-validated research to support patients during the decision-making process.

The data presented and views expressed in this document are the result of multiple published and unpublished studies over the last 25 years. My over-arching goal in this research was to use modern computing power to create functionally useful diagnoses, in real time, from the monitoring systems used during routine anaesthesia and to present these diagnoses in an ergonomic manner. In addition it was intended to incorporate into the anaesthetic monitor, expert systems that help with the management of uncommon situations. The Australian and New Zealand College guidelines on monitoring during anaesthesia dictate those measurements that should be made during every anaesthetic; from these data evidence can be gathered, integrated, and presented to the clinician. Constraints in this field of research include the inability of the monitors to see, hear or understand the context of operating theatre activities, and computer processing time. Because many studies are involved the methods are detailed in the main text, and are not summarized here. Physiological 'envelopes' have been developed, in which the 'normal' variation in physiological variables, during anaesthesia, are enclosed. They have enabled the creation of intelligent alarm systems that can suggest diagnoses. A retrospective off-line study showed that it was possible to diagnose the onset of malignant hyperpyrexia, using fuzzy logic templates, about 10minutes earlier than the clinician. Some variables may be more important than others in making a diagnosis, and the strength of a diagnosis depends on the amount of supporting evidence, the amount of evidence not against the diagnosis and the amount of missing data. Decision-making (for example to transfuse or not transfuse blood) can also be mathematically modelled so that decision making is more consistent. Finally, investigation of the ways of displaying data indicates that the output can be very explicit. My overall conclusion is that real time decision support systems for the management of clinical dilemmas are possible. They can be instantly and easily accessible and can sit discretely in the background of anaesthetic monitors to be activated at will by the anaesthetist.

This qualitative study describes how physical therapist experts in musculoskeletal disorders evaluate and interpret imaging studies and how they employ imaging in clinical decision-making. The informants are physical therapists who are certified orthopedic clinical specialists (OCS) and/or fellows of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). The study employed web conferencing to display patient cases, record screen-capture videos, and to conduct interviews. Informants were observed and their activity video-captured as they evaluated imaging studies and, afterwards, interviews were employed to explore the processes they utilized to evaluate and interpret the images and to discuss imaging-related clinical decision-making, including possible functional consequences of changes seen in the images, contraindications to treatment, and indications for referral. The interviews were transcribed and analyzed in the tradition of grounded theory. This study found that the informants’ evaluation of imaging studies was contextual and non-systematic, guided by the clinical presentation. The informants used imaging studies to provide a deeper understanding of clinical findings and widen perspectives, arriving at clinical decisions through the synthesis of imaging, clinical findings, and didactic knowledge. They tended to look for imaging evidence of interference with normal motion, rather than evidence of pathology. Overall, the informants expressed conservative views on the use of imaging, noting they would rather use clinical findings and treatment response than imaging findings as a basis for referral to other health care professionals. Using imaging studies to support clinical decision-making can provide physical therapists a wider perspective when planning treatment interventions. By showing physical therapists’ approach to interpreting imaging studies and how this relates to their clinical decision-making, the findings of this study could contribute to discussions of the place of imaging in physical therapist practice, as well as help set objectives for imaging curricula in professional-level and continuing education.

Each year millions of people face the medical decision-making cycle that comes with a diagnosis of cancer. For patients and their families, this can be a rollercoaster of confusion and fear. Researchers have indicated that the complexity of the decision-making process is underrepresented in the current approach of informed decision-making. The purpose of this study was to add to scientifically-validated research expanding the identification of factors that influence decision-making for individuals diagnosed with cancer. Fuzzy trace theory (FTT) is the dual process memory theory used as the framework for this study. Qualitative data were collected using semistructured interviews with 10 participants. The sampling strategy included purposeful sampling and snowball or chain sampling. The audio-recorded interviews were transcribed and analyzed. Software tools were used to aid in the creation of word mapping and clusters and a naming structure emerged. A comprehensive thematic analysis was completed. Participants detailed experiences with family and social dynamics, psychological or emotional stress, external influencing factors to the decision-making process, and experiences with cancer advertising. This research can create positive social change through the advancement of scientifically-validated research to support patients during the decision-making process.

The modern automobile is a complex electromechanical system controlled by control systems which consist of several interdependent electronic control units (ECUs). Analysis of the data generated by these modules is very important in order to observe the interesting patterns among data. At Volvo Cars Corporation today, diagnostic read-out data is retrieved from client machines installed at workshops in different countries around the world. The problem with this data is that it does not show a clear picture as what is causing what i.e. tracking the problem. Diagnostic engineers at Volvo Cars Corporation perform routine based statistical analysis of diagnostic read-out data manually, which is time consuming and tedious work. Moreover, this analysis is restricted to basic level mainly statistical analysis of diagnostic readout data. We present an approach based on statistical analysis and cluster analysis. Our approach focused on analysing the data from a pure statistical stand-point to isolate the problem in diagnostic read-out data, thereby helping to visualize and analyse the nature of the problem at hand. Different general statistical formulae were applied to get meaningful information from large amount of DRO data. Cluster analysis was carried out to get clusters consisting of similar trouble codes. Different methods and techniques were considered for the purpose of cluster analysis. Hierarchical and non-hierarchical clusters were extracted by applying appropriate algorithms. The results obtained from the thesis work show that the diagnostic read-out data consist of independent and interdependent fault codes. Groups were generated which consist of similar trouble codes. Furthermore, corresponding factors from freeze frame data which shows significant variation for these groups were also extracted. These faults, groups of faults and factors were later interpreted and validated by diagnostic engineers.