Adequacy of venous thromboprophylaxis in acutely ill medical patients (IMPART): multisite comparison of different clinical decision support systems

BACKGROUND: The adequacy of thromboprophylaxis prescriptions in acutely ill hospitalized medical patients needs improvement. OBJECTIVE: To prospectively assess the efficacy of thromboprophylaxis adequacy of various clinical decision support systems (CDSS) with the aim of increasing the use of explicit criteria for thromboprophylaxis prescription in nine Swiss medical services. METHODS: We randomly assigned medical services to a pocket digital assistant program (PDA), pocket cards (PC) and no CDSS (controls). In centers using an electronic chart, an e-alert system (eAlerts) was developed. After 4 months, we compared post-CDSS with baseline thromboprophylaxis adequacy for the various CDSS and control groups. RESULTS: Overall, 1085 patients were included (395 controls, 196 PC, 168 PDA, 326 eAlerts), 651 pre- and 434 post-CDSS implementation: 472 (43.5%) presented a risk of VTE justifying thromboprophylaxis (31.8% pre, 61.1% post) and 556 (51.2%) received thromboprophylaxis (54.2% pre, 46.8% post). The overall adequacy (% patients with adequate prescription) of pre- and post-CDSS implementation was 56.2 and 50.7 for controls (P = 0.29), 67.3 and 45.3 for PC (P = 0.002), 66.0 and 64.9 for PDA (P = 0.99), 50.5 and 56.2 for eAlerts (P = 0.37), respectively, eAlerts limited overprescription (56% pre, 31% post, P = 0.01). CONCLUSION: While pocket cards and handhelds did not improve thromboprophylaxis adequacy, eAlerts had a modest effect, particularly on the reduction of overprescription. This effect only partially contributes to the improvement of patient safety and more work is needed towards institution-tailored tools.

Systems medicine and integrated care to combat chronic noncommunicable diseases

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Farming Systems and Resilience Building in a Changing Climate On-Farm Comparisons of Organic and Conventional Cocoa Cultivation in Alto Beni, Bolivia

Resilience research has been applied to socioeconomic as well as for agroecological studies in the last 20 years. It provides a conceptual and methodological approach for a better understanding of interrelations between the performance of ecological and social systems. In the research area Alto Beni, Bolivia, the production of cocoa (Theobroma cacao L.), is one of the main sources of income. Farmers in the region have formed producers’ associations to enhance organic cocoa cultivation and obtain fair prices since the 1980s. In cooperation with the long-term system comparisons by the Research Institute of Organic Agriculture (FiBL) in Alto Beni, aspects of the field trial are applied for the use in on-farm research: a comparison of soil fertility, biomass and crop diversity is combined with qualitative interviews and participatory observation methods. Fieldwork is carried out together with Bolivian students through the Swiss KFPE-programme Echanges Universitaires. For the system comparisons, four different land-use types were classified according to their ecological complexity during a preliminary study in 2009: successional agroforestry systems, simple agroforestry systems (both organically managed and certified), traditional systems and conventional monocultures. The study focuses on interrelations between different ways of cocoa cultivation, livelihoods and the related socio-cultural rationales behind them. In particular this second aspect is innovative as it allows to broaden the biophysical perspective to a more comprehensive evaluation with socio-ecological aspects thereby increasing the relevance of the agronomic field studies for development policy and practice. Moreover, such a socio-ecological baseline allows to assess the potential of organic agriculture regarding resilience-building face to socio-environmental stress factors. Among others, the results of the pre-study illustrate local farmers’ perceptions of climate change and the consequences for the different crop-systems: all interviewees mentioned rising temperatures and/or an extended dry season as negative impacts more with regard to their own working conditions than to their crops. This was the case in particular for conventional monocultures and in plots where slash-and-burn cultivation was practised whereas for organic agroforestry systems the advantage of working in the shade was stressed indicating that their relevance rises in the context of climate change.

Comparison of cartilage histopathology assessment systems on human knee joints at all stages of osteoarthritis development

To compare the MANKIN and OARSI cartilage histopathology assessment systems using human articular cartilage from a large number of donors across the adult age spectrum representing all levels of cartilage degradation.

Milk cortisol concentration in automatic milking systems compared with auto-tandem milking parlors

Milk cortisol concentration was determined under routine management conditions on 4 farms with an auto-tandem milking parlor and 8 farms with 1 of 2 automatic milking systems (AMS). One of the AMS was a partially forced (AMSp) system, and the other was a free cow traffic (AMSf) system. Milk samples were collected for all the cows on a given farm (20 to 54 cows) for at least 1 d. Behavioral observations were made during the milking process for a subset of 16 to 20 cows per farm. Milk cortisol concentration was evaluated by milking system, time of day, behavior during milking, daily milk yield, and somatic cell count using linear mixed-effects models. Milk cortisol did not differ between systems (AMSp: 1.15 +/- 0.07; AMSf: 1.02 +/- 0.12; auto-tandem parlor: 1.01 +/- 0.16 nmol/L). Cortisol concentrations were lower in evening than in morning milkings (1.01 +/- 0.12 vs. 1.24 +/- 0.13 nmol/L). The daily periodicity of cortisol concentration was characterized by an early morning peak and a late afternoon elevation in AMSp. A bimodal pattern was not evident in AMSf. Finally, milk cortisol decreased by a factor of 0.915 in milking parlors, by 0.998 in AMSp, and increased by a factor of 1.161 in AMSf for each unit of ln(somatic cell count/1,000). We conclude that milking cows in milking parlors or AMS does not result in relevant stress differences as measured by milk cortisol concentrations. The biological relevance of the difference regarding the daily periodicity of milk cortisol concentrations observed between the AMSp and AMSf needs further investigation.

Characterization of microfluidic systems with Doppler optical coherence tomography

Doppler Optical Coherence Tomography (DOCT) is a biomedical imaging technique that allows simultaneous structural imaging and flow monitoring inside biological tissues and materials with spatial resolution in the micrometer scale. It has recently been applied to the characterization of microfluidic systems. Structural and flow imaging of novel microfluidics platforms for cytotoxicologic applications were obtained with a real-time, Near Infrared Spectral Domain DOCT system. Characteristics such as flow homogeneity in the chamber, which is one of the most important parameters for cell culture, are investigated. OCT and DOCT images were used to monitor flow inside a specific platform that is based on microchannel division for a better flow homogeneity. In particular, the evolution of flow profile at the transition between the microchannel structure and the chamber is studied.