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Article ; Online: Clinical reasoning for the continuation or discontinuation of hip precautions after total hip arthroplasty in Switzerland: a qualitative study.

Krygowski, Jaroslaw / Reicherzer, Leah / Marcin, Thimo

2024 Volume 154, Page(s) 3536

Abstract: Background: Growing evidence raises doubts about the need for routine hip precautions after primary total hip replacements to reduce the risk of postoperative dislocation. However, hip precautions are still routinely and widely prescribed in ... ...

Abstract	Background: Growing evidence raises doubts about the need for routine hip precautions after primary total hip replacements to reduce the risk of postoperative dislocation. However, hip precautions are still routinely and widely prescribed in postoperative care in Switzerland. We aimed to investigate experts' clinical reasoning for hip precaution recommendations after total hip arthroplasty. Methods: Using a convenience sampling strategy, 14 semi-structured expert interviews were conducted with surgeons, physiotherapists, and occupational therapists in the vicinity of an inpatient rehabilitation clinic in Switzerland. Data analysis followed Mayring's principle of inductive and deductive structuring content analysis. Results: Expert statements from the interviews were summarised into four main categories and 10 subcategories. Categories included statements on the incidences of dislocation and underlying risk factors; current preferences and use of hip precautions; their effect on physical function, anxiety, or costs; and patient's adherence to the movement restrictions. Hip surgeons routinely prescribed hip precautions, although in different variations. Fear of dislocation and caution are barriers to changing current practice. Some surgeons are considering individualised prescribing based on patients' risk of dislocation, which therapists would welcome. Conclusion: A lack of clear instructions from the surgeon leads to ambiguity among therapists outside the acute hospital. A shared understanding of the need for and nature of hip precautions, guidelines from societies, or at least specific instructions from surgeons to therapists are warranted.
MeSH term(s)	Humans ; Arthroplasty, Replacement, Hip ; Hip Dislocation/epidemiology ; Hip Dislocation/etiology ; Switzerland ; Postoperative Complications/prevention & control ; Postoperative Complications/etiology ; Postoperative Care/adverse effects
Language	English
Publishing date	2024-01-04
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2036179-8
ISSN	1424-3997 ; 1424-7860
ISSN (online)	1424-3997
ISSN	1424-7860
DOI	10.57187/s.3536
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Article ; Online: Efficacy of a digital lifestyle intervention on health-related QUAlity of life in non-small cell LUng CAncer survivors following inpatient rehabilitation: protocol of the QUALUCA Swiss multicentre randomised controlled trial.

Weber, Manuel / Raab, Anja Maria / Schmitt, Kai-Uwe / Büsching, Gilbert / Marcin, Thimo / Spielmanns, Marc / Puhan, Milo Alan / Frei, Anja

BMJ open

2024 Volume 14, Issue 3, Page(s) e081397

Abstract: Introduction: Non-small cell lung cancer (NSCLC) survivors suffer from impaired physical and psychological functioning and reduced health-related quality of life (HRQoL) that persist after active treatment ends. Sustaining rehabilitation benefits, ... ...

Abstract	Introduction: Non-small cell lung cancer (NSCLC) survivors suffer from impaired physical and psychological functioning and reduced health-related quality of life (HRQoL) that persist after active treatment ends. Sustaining rehabilitation benefits, promoting a healthy lifestyle and facilitating self-management at home require a multifaceted aftercare programme. We aim to investigate the effect of a 12-week digital lifestyle intervention on HRQoL and lifestyle-related outcomes in NSCLC survivors after completion of inpatient rehabilitation. Methods and analysis: QUAlity of life in LUng CAncer Survivors (QUALUCA) is a multicentre randomised controlled trial that follows a hybrid type 1 design. We randomly allocate participants in a 1:1 ratio to the intervention group (digital lifestyle intervention) or the control group (standard care) using block randomisation stratified by tumour stage and study site. Four accredited Swiss inpatient rehabilitation centres recruit participants. Key inclusion criteria are a diagnosis of NSCLC, an estimated life expectancy of ≥6 months and access to a smartphone or tablet. The 12-week intervention comprises physical activity, nutrition and breathing/relaxation, delivered through a mobile application (app). The primary outcome is the change in HRQoL from baseline (1 week after rehabilitation) to follow-up (3 months after baseline), assessed by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Secondary outcomes include body mass index, self-reported physical activity, exercise capacity, risk of low protein intake, appetite, psychological distress, cancer-related fatigue, enablement and self-rated health. Explanatory outcomes in the intervention group include app usability, acceptability, appropriateness, and feasibility of the intervention, experiences and satisfaction with the intervention, and app usage data. We aim to enrol 88 participants. For the main statistical analysis, we will use analysis of covariance, adjusted for baseline measures, stratification variables, age and sex. Ethics and dissemination: The Ethics Committees of the Canton of Zurich (lead), the Canton of Bern and Northwest and Central Switzerland approved the study (2023-00245). We will disseminate study results to researchers, health professionals, study participants and relevant organisations, and through publications in international peer-reviewed journals. Trial registration number: NCT05819346.
MeSH term(s)	Humans ; Quality of Life ; Carcinoma, Non-Small-Cell Lung ; Inpatients ; Switzerland ; Lung Neoplasms ; Survivors ; Life Style ; Randomized Controlled Trials as Topic ; Multicenter Studies as Topic
Language	English
Publishing date	2024-03-07
Publishing country	England
Document type	Clinical Trial Protocol ; Journal Article
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-081397
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Article ; Online: Is language an issue? Accuracy of the German computerized diagnostic decision support system ISABEL and cross-validation with the English counterpart.

Marcin, Thimo / Lüthi, Ailin / Graf, Ronny R / Krummrey, Gert / Schauber, Stefan K / Breakey, Neal / Hautz, Wolf E / Hautz, Stefanie C

Diagnosis (Berlin, Germany)

2023 Volume 10, Issue 4, Page(s) 398–405

Abstract: Objectives: Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients ...

Abstract	Objectives: Existing computerized diagnostic decision support tools (CDDS) accurately return possible differential diagnoses (DDx) based on the clinical information provided. The German versions of the CDDS tools for clinicians (Isabel Pro) and patients (Isabel Symptom Checker) from ISABEL Healthcare have not been validated yet. Methods: We entered clinical features of 50 patient vignettes taken from an emergency medical text book and 50 real cases with a confirmed diagnosis derived from the electronic health record (EHR) of a large academic Swiss emergency room into the German versions of Isabel Pro and Isabel Symptom Checker. We analysed the proportion of DDx lists that included the correct diagnosis. Results: Isabel Pro and Symptom Checker provided the correct diagnosis in 82 and 71 % of the cases, respectively. Overall, the correct diagnosis was ranked in 71 , 61 and 37 % of the cases within the top 20, 10 and 3 of the provided DDx when using Isabel Pro. In general, accuracy was higher with vignettes than ED cases, i.e. listed the correct diagnosis more often (non-significant) and ranked the diagnosis significantly more often within the top 20, 10 and 3. On average, 38 ± 4.5 DDx were provided by Isabel Pro and Symptom Checker. Conclusions: The German versions of Isabel achieved a somewhat lower accuracy compared to previous studies of the English version. The accuracy decreases substantially when the position in the suggested DDx list is taken into account. Whether Isabel Pro is accurate enough to improve diagnostic quality in clinical ED routine needs further investigation.
MeSH term(s)	Humans ; Dichlorodiphenyl Dichloroethylene ; Research Design ; Diagnosis, Differential ; Electronic Health Records ; Language
Chemical Substances	Dichlorodiphenyl Dichloroethylene (4M7FS82U08)
Language	English
Publishing date	2023-07-24
Publishing country	Germany
Document type	Journal Article
ISSN	2194-802X
ISSN (online)	2194-802X
DOI	10.1515/dx-2023-0047
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Article ; Online: Effect of self-tailored high-intensity interval training versus moderate-intensity continuous exercise on cardiorespiratory fitness after myocardial infarction: A randomised controlled trial.

Marcin, Thimo / Trachsel, Lukas D / Dysli, Michelle / Schmid, Jean Paul / Eser, Prisca / Wilhelm, Matthias

Annals of physical and rehabilitation medicine

2021 Volume 65, Issue 1, Page(s) 101490

Abstract: Background: Whether high-intensity interval training (HIIT) is more efficient than moderate-intensity continuous exercise (MICE) to increase cardiorespiratory fitness in patients with acute coronary syndrome at moderate-to-high cardiovascular risk is ... ...

Abstract	Background: Whether high-intensity interval training (HIIT) is more efficient than moderate-intensity continuous exercise (MICE) to increase cardiorespiratory fitness in patients with acute coronary syndrome at moderate-to-high cardiovascular risk is controversial. The best approach to guide training intensity remains to be determined. Objective: We aimed to assess intensities achieved with self-tailored HIIT and MICE according to perceived exertion and to compare the effect on cardiorespiratory fitness in patients early after ST-elevation myocardial infarction (STEMI). Methods: We included 69 males starting cardiac rehabilitation within 4 weeks after STEMI. After a 3-week run-in phase with MICE, 35 patients were randomised to 9 weeks of HIIT (2×HIIT and 1×MICE per week) and 34 patients to MICE (3×MICE). Training workload for MICE was initially set at the patients' first ventilatory threshold (VT). HIIT consisted of 4×4-min intervals with a workload above the second VT in high intervals. Training intensity was adjusted weekly to maintain the perceived exertion (Borg score 13-14 for MICE, ≥15 for HIIT). Session duration was 38min in both groups. Peak oxygen consumption (VO Results: Both groups improved peak VO Conclusions: Self-tailored HIIT was feasible in patients early after STEMI. It was more strenuous but not superior nor more time-efficient than MICE in improving peak VO
Language	English
Publishing date	2021-11-21
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	2480363-7
ISSN	1877-0665 ; 1877-0657
ISSN (online)	1877-0665
ISSN	1877-0657
DOI	10.1016/j.rehab.2021.101490
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Article ; Online: Patient interest in mHealth as part of cardiac rehabilitation in Switzerland.

Marcin, Thimo / Bengel, Christian / Goldberg, Tabea / Peterhans, Judith / Eser, Prisca / Wilhelm, Matthias

Swiss medical weekly

2021 Volume 151, Page(s) w20510

Abstract: Purpose: Smartphone-based health interventions (mHealth) offer the potential to overcome barriers to accessibility of cardiac rehabilitation. We aimed (1) to examine patients’ interest in mHealth as part of the outpatient cardiac rehabilitation (phase ... ...

Abstract	Purpose: Smartphone-based health interventions (mHealth) offer the potential to overcome barriers to accessibility of cardiac rehabilitation. We aimed (1) to examine patients’ interest in mHealth as part of the outpatient cardiac rehabilitation (phase II) and long-term aftercare (phase III) and (2) to identify the influence of sociodemographic and clinical patient characteristics on interest in mHealth. Methods: A questionnaire was consecutively handed out to 2041 patients concluding outpatient cardiac rehabilitation between March 2013 and December 2018 at the University Hospital Bern. Multivariate logistic models were used to identify influencing factors (age, sex, smartphone ownership, year, compliance with cardiac rehabilitation, physical fitness, body mass index, diabetes mellitus, German speaking) for mHealth interest. Results: The questionnaire was returned by 1025 patients (50.2% response rate). Seventy-one percent of the responding patients preferred the cardiac rehabilitation as offered with three weekly centre-based sessions, whereas 12% preferred and 17% considered replacing two out of the three centre-based sessions per week with mHealth. Forty-eight percent were interested in continuing exercise training using mHealth after completion of cardiac rehabilitation. Smartphone ownership was the most important indicator for patient interest in mHealth (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.53–4.23), whereas age (per year) was not independently associated with mHealth interest for phase II (OR 0.99, 95% CI 0.98–1.01) and only weakly associated with phase III (OR 0.98, 95% CI 0.96–0.99). Conclusion: In a Swiss urban region with easy access to cardiac rehabilitation, patients who participated in a centre-based cardiac rehabilitation programme between 2013 and 2018 showed little interest in mHealth during phase II. However, almost half of them expressed interest in continuing training with mHealth during phase III.
MeSH term(s)	Cardiac Rehabilitation ; Humans ; Physical Fitness ; Smartphone ; Switzerland ; Telemedicine
Language	English
Publishing date	2021-05-07
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2036179-8
ISSN	1424-3997 ; 1424-7860
ISSN (online)	1424-3997
ISSN	1424-7860
DOI	10.4414/smw.2021.20510
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Article: Time-Dependent Effect of Anthracycline-Based Chemotherapy on Central Arterial Stiffness: A Systematic Review and Meta-Analysis.

Schneider, Caroline / González-Jaramillo, Nathalia / Marcin, Thimo / Campbell, Kristin L / Suter, Thomas / Bano, Arjola / Wilhelm, Matthias / Eser, Prisca

Frontiers in cardiovascular medicine

2022 Volume 9, Page(s) 873898

Abstract: Background and aims: Anthracycline-based chemotherapy (ANTH-BC) has been proposed to increase arterial stiffness, however, the time-dependency of these effects remain unclear. This systematic review and meta-analysis aimed to investigate the time- ... ...

Abstract	Background and aims: Anthracycline-based chemotherapy (ANTH-BC) has been proposed to increase arterial stiffness, however, the time-dependency of these effects remain unclear. This systematic review and meta-analysis aimed to investigate the time-dependent effect of ANTH-BC on markers of central aortic stiffness, namely aortic distensibility (AD) and pulse-wave-velocity (PWV) in cancer patients. Methods: An extensive literature search without language restrictions was performed to identify all studies presenting longitudinal data on the effect of ANTH-BC on either AD and/or central PWV in cancer patients of all ages. An inverse-variance weighted random-effect model was performed with differences from before to after chemotherapy, as well as for short vs. mid-term effects. Results: Of 2,130 articles identified, 9 observational studies with a total of 535 patients (mean age 52 ± 11; 73% women) were included, of which four studies measured AD and seven PWV. Short-term (2-4 months), there was a clinically meaningful increase in arterial stiffness, namely an increase in PWV of 2.05 m/s (95% CI 0.68-3.43) and a decrease in AD (albeit non-significant) of -1.49 mmHg-1 (-3.25 to 0.27) but a smaller effect was observed mid-term (6-12 months) for PWV of 0.88 m/s (-0.25 to 2.02) and AD of -0.37 mmHg-1 (-1.13 to 0.39). There was considerable heterogeneity among the studies. Conclusions: Results from this analysis suggest that in the short-term, ANTH-BC increases arterial stiffness, but that these changes may partly be reversible after therapy termination. Future studies need to elucidate the long-term consequences of ANTH-BC on arterial stiffness, by performing repeated follow-up measurements after ANTH-BC termination. Systematic review registration: [www.crd.york.ac.uk/prospero/], identifier [CRD42019141837].
Language	English
Publishing date	2022-07-05
Publishing country	Switzerland
Document type	Systematic Review
ZDB-ID	2781496-8
ISSN	2297-055X
ISSN	2297-055X
DOI	10.3389/fcvm.2022.873898
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Article: Young endurance training starting age in non-elite athletes is associated with higher proximal aortic distensibility.

Ryffel, Christoph P / Eser, Prisca / Marcin, Thimo / Herrsche, Dario / Brugger, Nicolas / Trachsel, Lukas D / Wilhelm, Matthias

Open heart

2022 Volume 9, Issue 1

Abstract: Objective: Decreased proximal aortic distensibility (AD) is known to significantly predict all-cause mortality and cardiovascular events among individuals without overt cardiovascular disease. This cross-sectional study investigated the association of ... ...

Abstract	Objective: Decreased proximal aortic distensibility (AD) is known to significantly predict all-cause mortality and cardiovascular events among individuals without overt cardiovascular disease. This cross-sectional study investigated the association of endurance training (ET) parameters, namely, ET starting age, ET years and yearly ET volume with AD in non-elite endurance athletes. Methods: Healthy, normotensive, male Caucasian participants of a 10-mile race were assessed with a 2D echocardiogram and comprehensive interview. Ascending aortic diameters were measured simultaneously with pulse pressure. Aortic strain, AD and aortic stiffness index were calculated. Predictors of AD were investigated among training parameters by linear regression models corrected for age, resting heart rate, stroke volume index and mean blood pressure. Results: Ninety-two of 121 athletes (aged 42±8 years) had sufficient echocardiogram quality and were used for analysis. ET starting age (range 6-52 years) and years of ET (range 2-46 years) were highly collinear and used in two separate models for AD. Significant factors for AD were ET starting age, 10-mile race time and resting heart rate in model I, and age, years of ET, 10-mile race time and heart rate in model II (all p<0.01). Conclusions: In our cohort of healthy, non-elite, middle-aged runners, AD was significantly higher in athletes with younger ET starting age or more years of ET (in the model adjusted for confounders). In the model with years of ET, age had a negative contribution to AD, suggesting that with older age, the benefit of more years of ET on AD decreased. Future studies assessing the effect of exercise training on arterial properties should include training starting age.
MeSH term(s)	Aorta/diagnostic imaging ; Aorta/physiology ; Athletes ; Child ; Cross-Sectional Studies ; Echocardiography ; Endurance Training ; Humans ; Male ; Middle Aged
Language	English
Publishing date	2022-03-09
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2747269-3
ISSN	2053-3624
ISSN	2053-3624
DOI	10.1136/openhrt-2021-001771
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Article ; Online: Accurate Prediction Equations for Ventilatory Thresholds in Cardiometabolic Disease When Gas Exchange Analysis is Unavailable: Development and Validation.

Milani, Juliana Goulart Prata Oliveira / Milani, Mauricio / Machado, Felipe Vilaça Cavallari / Wilhelm, Matthias / Marcin, Thimo / D'Ascenzi, Flavio / Cavigli, Luna / Keytsman, Charly / Falter, Maarten / Bonnechere, Bruno / Meesen, Raf / Braga, Fabrício / Cipriano, Graziella França Bernardelli / Cornelissen, Veronique / Verboven, Kenneth / Junior, Gerson Cipriano / Hansen, Dominique

European journal of preventive cardiology

2024

Abstract: Aims: To develop and validate equations predicting heart rate (HR) at the first and second ventilatory thresholds (VTs) and an optimized range-adjusted prescription for patients with cardiometabolic disease (CMD). To compare their performance against ... ...

Abstract	Aims: To develop and validate equations predicting heart rate (HR) at the first and second ventilatory thresholds (VTs) and an optimized range-adjusted prescription for patients with cardiometabolic disease (CMD). To compare their performance against guideline-based exercise intensity domains. Methods: Cross-sectional study involving 2,868 CMD patients from nine countries. HR predictive equations for first and second VTs (VT1, VT2) were developed using multivariate linear regression with 975 cycle-ergometer cardiopulmonary exercise tests (CPET). 'Adjusted' percentages of peak HR (%HRpeak) and HR reserve (%HRR) were derived from this group. External validation with 1,893 CPET (cycle-ergometer or treadmill) assessed accuracy, agreement, and reliability against guideline-based %HRpeak and %HRR prescriptions using mean absolute percentage error (MAPE), Bland-Altman analyses, intraclass correlation coefficients (ICC). Results: HR predictive equations (R²: 0.77 VT1, 0.88 VT2) and adjusted %HRR (VT1: 42%, VT2: 77%) were developed. External validation demonstrated superiority over widely used guideline-directed intensity domains for %HRpeak and %HRR. The new methods showed consistent performance across both VTs with lower MAPE (VT1: 7.1%, VT2: 5.0%), 'good' ICC for VT1 (0.81, 0.82) and 'excellent' for VT2 (0.93). Guideline-based exercise intensity domains had higher MAPE (VT1: 6.8%-21.3%, VT2: 5.1%-16.7%), 'poor' to 'good' ICC for VT1, and 'poor' to 'excellent' for VT2, indicating inconsistencies related to specific VTs across guidelines. Conclusion: Developed and validated HR predictive equations and the optimized %HRR for CMD patients for determining VT1 and VT2 outperformed the guideline-based exercise intensity domains and showed ergometer interchangeability. They offer a superior alternative for prescribing moderate intensity exercise when CPET is unavailable.
Language	English
Publishing date	2024-04-18
Publishing country	England
Document type	Journal Article
ZDB-ID	2626011-6
ISSN	2047-4881 ; 2047-4873
ISSN (online)	2047-4881
ISSN	2047-4873
DOI	10.1093/eurjpc/zwae149
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Article: The Role of Environmental Conditions on Master Marathon Running Performance in 1,280,557 Finishers the 'New York City Marathon' From 1970 to 2019.

Knechtle, Beat / McGrath, Carlyn / Goncerz, Olivia / Villiger, Elias / Nikolaidis, Pantelis Theodoros / Marcin, Thimo / Sousa, Caio Victor

Frontiers in physiology

2021 Volume 12, Page(s) 665761

Abstract: Aim: ...

Abstract	Aim:
Language	English
Publishing date	2021-05-17
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2564217-0
ISSN	1664-042X
ISSN	1664-042X
DOI	10.3389/fphys.2021.665761
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Article ; Online: Effects of a computerised diagnostic decision support tool on diagnostic quality in emergency departments: study protocol of the DDx-BRO multicentre cluster randomised cross-over trial.

Marcin, Thimo / Hautz, Stefanie C / Singh, Hardeep / Zwaan, Laura / Schwappach, David / Krummrey, Gert / Schauber, Stefan K / Nendaz, Mathieu / Exadaktylos, Aristomenis Konstantinos / Müller, Martin / Lambrigger, Cornelia / Sauter, Thomas C / Lindner, Gregor / Bosbach, Simon / Griesshammer, Ines / Hautz, Wolf E

BMJ open

2023 Volume 13, Issue 3, Page(s) e072649

Abstract: Introduction: Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and ... ...

Abstract	Introduction: Computerised diagnostic decision support systems (CDDS) suggesting differential diagnoses to physicians aim to improve clinical reasoning and diagnostic quality. However, controlled clinical trials investigating their effectiveness and safety are absent and the consequences of its use in clinical practice are unknown. We aim to investigate the effect of CDDS use in the emergency department (ED) on diagnostic quality, workflow, resource consumption and patient outcomes. Methods and analysis: This is a multicentre, outcome assessor and patient-blinded, cluster-randomised, multiperiod crossover superiority trial. A validated differential diagnosis generator will be implemented in four EDs and randomly allocated to a sequence of six alternating intervention and control periods. During intervention periods, the treating ED physician will be asked to consult the CDDS at least once during diagnostic workup. During control periods, physicians will not have access to the CDDS and diagnostic workup will follow usual clinical care. Key inclusion criteria will be patients' presentation to the ED with either fever, abdominal pain, syncope or a non-specific complaint as chief complaint. The primary outcome is a binary diagnostic quality risk score composed of presence of an unscheduled medical care after discharge, change in diagnosis or death during time of follow-up or an unexpected upscale in care within 24 hours after hospital admission. Time of follow-up is 14 days. At least 1184 patients will be included. Secondary outcomes include length of hospital stay, diagnostics and data regarding CDDS usage, physicians' confidence calibration and diagnostic workflow. Statistical analysis will use general linear mixed modelling methods. Ethics and dissemination: Approved by the cantonal ethics committee of canton Berne (2022-D0002) and Swissmedic, the Swiss national regulatory authority on medical devices. Study results will be disseminated through peer-reviewed journals, open repositories and the network of investigators and the expert and patients advisory board. Trial registration number: NCT05346523.
MeSH term(s)	Humans ; Cross-Over Studies ; Research Design ; Hospitalization ; Emergency Service, Hospital ; Randomized Controlled Trials as Topic ; Multicenter Studies as Topic
Language	English
Publishing date	2023-03-29
Publishing country	England
Document type	Clinical Trial Protocol ; Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-072649
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