Biliary Strictures: A Surgeon's Perspective for Interventional Radiologists

2021 ◽  
Vol 38 (03) ◽  
pp. 273-279
Author(s):  
Nitin Katariya ◽  
Amit K. Mathur
Keyword(s):  
Clinical Decision Making ◽  
Biliary Stricture ◽  
Extrahepatic Bile Duct ◽  
Adult Population ◽  
Symptom Relief ◽  
Clinical Problem ◽  
Clinical Decision ◽  
Biliary Strictures ◽  
Surgical History ◽  
New Diagnosis

AbstractBiliary strictures can be a challenging clinical problem to manage and often have unclear etiologies, including benign and malignant causes. Left untreated, these problems can lead to significant morbidity and mortality linked to their underlying diagnosis. The approach to adult patients with biliary strictures requires a multidisciplinary team involving surgeons, interventional endoscopists, and interventional radiologists for diagnosis, symptom relief, palliation, as well as potential curative management. From a surgeon's perspective, there are many ways to classify and approach these strictures. It is of paramount importance to start with an excellent understanding of the patient's prior surgical history. In approaching a patient with a new diagnosis of biliary stricture, it is also critical to understand its etiology relatively quickly, as 70% are malignant in the adult population. Concurrently, one must clearly define the location and extent of the stricture: intrahepatic, hilar, or distal extrahepatic bile duct, as well as whether it is a singular lesion or multifocal phenotypes. This information provides a path forward in clinical decision-making regarding durability and efficacy of therapy, which is typically aimed at decompression and/or surgical resection to prevent cholangitis, sepsis, and progressive hepatic insufficiency.

Clinical Problem Solving: Decreased Level of Consciousness and Unexplained Hydrocephalus

2022 ◽  
pp. 194187442110567
Author(s):  
Naomi Niznick ◽  
Ronda Lun ◽  
Daniel A. Lelli ◽  
Tadeu A. Fantaneanu
Keyword(s):  
Decision Making ◽  
Differential Diagnosis ◽  
Clinical Decision Making ◽  
Clinical Problem ◽  
Clinical Decision ◽  
Decision Making Process ◽  
Clinical Problem Solving ◽  
Level Of Consciousness ◽  
History Of

We present a clinical reasoning case of 42-year-old male with a history of type 1 diabetes who presented to hospital with decreased level of consciousness. We review the approach to coma including initial approach to differential diagnosis and investigations. After refining the diagnostic options based on initial investigations, we review the clinical decision-making process with a focus on narrowing the differential diagnosis, further investigations, and treatment.

scholarly journals Problem based curricula and problem based learning in physiotherapy: A critical review

2001 ◽  
Vol 57 (4) ◽  
pp. 23-28 ◽  
Author(s):  
C. A. Eksteen ◽  
J. A. Slabbert
Keyword(s):  
Health Care ◽  
Clinical Decision Making ◽  
Problem Based Learning ◽  
Educational Practice ◽  
Clinical Problem ◽  
Clinical Decision ◽  
Traditional Curriculum ◽  
Clinical Problem Solving ◽  
Basic Characteristics ◽  
Problem Solvers

Introduction: Problem based curricula and problem based learning are used extensively to facilitate learners to become effective learners and through that, effective professional problem solvers. The basic characteristics of the problem based curriculum and the processes of the problem based learning are described in the literature but many variations of problem based learning and the problem based curriculum exist. Research findings are also contradictory regarding the effectiveness of these approaches. The aim of this article is to discuss the theoretical foundation of these approaches and to identify the core issues that must be addressed in order to optimize their effect on learners.Methodology: A literature search was done by using the following keywords: problem based curriculum, problem based learning, clinical decision making, clinical problem solving, clinical judgement, physiotherapy, medicine, health care, and health care education.Discussion: There is a lack of research in the literature that shows evidence that the problem based curricula and problem based learning is more beneficial for students’ learning or mastering specific competencies than learning in a traditional curriculum. Papers on problem based curriculum and problem based learning describe the process and state the desired effects of the teaching approaches without explicitly describing the contextual and transactional environments, as well as the internal (departmental) environment in which the change in teaching approach took place and how it was adapted to their situation. Furthermore, no research could be found on ways to address the negative outcomes of problem based learning. There is thus a need for well designed research protocols to show the best evidence of physiotherapy educational practice.

Integrative Nursing and Symptom Management

2014 ◽  
pp. 187-199
Author(s):  
Debbie Ringdahl
Keyword(s):  
Symptom Management ◽  
Clinical Decision Making ◽  
Treatment Options ◽  
Symptom Relief ◽  
Clinical Decision ◽  
Nursing Interventions ◽  
Evidence Based ◽  
Integrative Health ◽  
Therapeutic Value ◽  
Whole Person

The principles of integrative nursing are reintroduced within the context of clinical decision making. Nursing interventions aimed at symptom relief support and facilitate whole person healing by using a range of approaches and evidence-based healing modalities. The integrative nurses assess mindbodyspirit while attending to physiologic systems and their interactions with the whole person. The focus on healing instead of curing shifts priorities and problem solving to include a wider range of treatment options. Increased use of integrative health modalities expands treatment options but also reminds nurses of the therapeutic value and healing potential of touch, comfort, and presence. Operationalizing integrative nursing principles requires “pragmatic idealism,” a task well suited to a profession invested in both the art and science of healing.

scholarly journals Oral Surgical Management of Bone and Soft Tissues in MRONJ Treatment: A Decisional Tree

Life ◽  
2020 ◽  
Vol 10 (7) ◽  
pp. 99 ◽  
Author(s):  
Antonia Marcianò ◽  
Erasmo Rubino ◽  
Matteo Peditto ◽  
Rodolfo Mauceri ◽  
Giacomo Oteri
Keyword(s):  
Clinical Decision Making ◽  
Soft Tissues ◽  
Oral Surgery ◽  
Symptom Relief ◽  
Treatment Algorithm ◽  
Clinical Decision ◽  
Surgical Approaches ◽  
Patient Centered ◽  
Necrotic Bone ◽  
Flap Design

Background: The aim of the present work was to analyze a 10-year retrospective series of surgically treated medication-related osteonecrosis of the jaws (MRONJ) cases, reporting the clinical outcome and success rate for each adopted procedure in order to draw a treatment algorithm that is able to standardize clinical decision making and maximize the success of oral surgical treatment of MRONJ. Methods: Different surgical approaches were categorized taking into consideration two variables (a) hard tissue management (defined as debridement, saucerization or marginal resective surgery of maxillary necrotic bone) and (b) soft tissue management (defined as type of flap design and related modality of wound-healing). Results: For the retrospective cohort study, 103 MRONJ patients were enrolled and a total of 128 surgical procedures were performed. The role of radical-intended surgery using local flaps in MRONJ treatment was investigated, as well as palliative treatments. All stage I–II patients completely healed when a combination of radical necrotic bone surgery associated with a first intention healing of soft tissues was obtained. In stage III, when a patient was not eligible for maxillo-facial surgery, the use of palliative surgical strategies was effective in symptom relief in order to maintain a better quality of life for the duration of the patient’s life. Conclusions: Oral surgery with radical intent associated with a flap design able to ensure first intention healing might represent a valid option for the majority of MRONJ patients. The designed decision tree allows clinicians to assess individual surgical approaches for MRONJ treatment in accordance with patient-centered outcomes and surgical skills.

Management of pediatric intracranial gunshot wounds: predictors of favorable clinical outcome and a new proposed treatment paradigm

2012 ◽  
Vol 10 (6) ◽  
pp. 511-517 ◽  
Author(s):  
S. Kathleen Bandt ◽  
Jacob K. Greenberg ◽  
Chester K. Yarbrough ◽  
Kenneth B. Schechtman ◽  
David D. Limbrick ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Clinical Decision Making ◽  
Pediatric Population ◽  
Adult Population ◽  
Gunshot Wounds ◽  
Clinical Decision ◽  
Gunshot Injury ◽  
Predictive Values ◽  
Treatment Paradigm ◽  
Favorable Clinical Outcome

Object There has been an increase in civilian gun violence since the late 1980s, with a disproportionately high increase occurring within the pediatric population. To date, no definite treatment paradigm exists for the management of these patients, nor is there a full understanding of the predictors of favorable clinical outcome in this population. Methods The authors completed a retrospective review of all victims of intracranial gunshot injury from birth to age 18 years at a major metropolitan Level 1 trauma center (n = 48) from 2002 to 2011. The predictive values of widely accepted adult clinical and radiographic factors for poor prognosis were investigated. Results Eight statistically significant factors (p < 0.05) for favorable outcome were identified. These factors include single hemispheric involvement, absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, systolic blood pressure > 100 mm Hg on arrival, absence of deep nuclei and/or third ventricular involvement, initial ICP < 30 mm Hg when monitored, and absence of midline shift. Of these 8 factors, 5 were strong predictors of favorable clinical outcome as defined by Glasgow Outcome Scale score of 4 or 5. These predictive factors included absence of a transventricular trajectory, < 3 lobes involved, ≥ 1 reactive pupil on arrival, absence of deep nuclei and/or third ventricular involvement, and initial ICP < 30 mm Hg. These findings form the basis of the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a novel metric to inform treatment decisions for pediatric patients who sustain these devastating injuries. Conclusions The pediatric population tends to demonstrate more favorable outcomes following intracranial gunshot injury when compared with the adult population; therefore some patients may benefit from more aggressive treatment than is considered for adults. The St. Louis Scale for Pediatric Gunshot Wounds to the Head may provide critical data toward evidence-based guidelines for clinical decision making.

scholarly journals Adrenal incidentalomas — a continuing management dilemma

2005 ◽  
Vol 12 (3) ◽  
pp. 585-598 ◽  
Author(s):  
R Nawar ◽  
D Aron
Keyword(s):  
Clinical Decision Making ◽  
Imaging Techniques ◽  
Clinical Problem ◽  
Clinical Decision ◽  
National Institutes Of Health ◽  
Adrenal Tumors ◽  
Adrenal Incidentalomas ◽  
Diagnostic Strategies ◽  
Clinically Significant ◽  
State Of The Science

Adrenal incidentalomas (AI), adrenal tumors detected through an imaging procedure done for reasons unrelated to adrenal dysfunction, is becoming a common clinical problem with the more frequent utilization of different imaging techniques. Most such tumors are benign and hormonally inactive. A variety of diagnostic strategies have been developed to distinguish the latter; however, they are still controversial. Even after a commissioned systematic review of the literature and a state of the science conference sponsored by the National Institutes of Health, the optimal strategy for hormonal screening of a patient with AI is unknown, but we anticipate further refinements and major advances in the field. Surgery is the ultimate solution for the diagnostic-therapeutic dilemma of AI. Careful planning is required, and the learning curve which influences clinical decision making is especially relevant to immediate outcomes. The benefit of making a diagnosis of a clinically significant AI must be considered in the context of the patient’s overall condition and preferences.

scholarly journals Evidence-based medicine and psychiatry

1997 ◽  
Vol 14 (3) ◽  
pp. 83-84 ◽  
Author(s):  
John Geddes
Keyword(s):  
Evidence Based Medicine ◽  
Clinical Decision Making ◽  
Clinical Problem ◽  
Clinical Decision ◽  
Evidence Based ◽  
Clinical Expertise ◽  
Medline Search ◽  
Research Findings ◽  
Definition Of ◽  
Based Medicine

Over the last five years the adjective ‘evidence-based’ has become difficult to avoid. Indeed, a MEDLINE search for articles containing the phrase ‘evidence-based medicine’ in their titles or abstracts reveals one mention in 1992, rapidly increasing to 53 in 1996. So great has been the increase that the National Library of Medicine now includes ‘evidence-based medicine’ as a MeSH heading for indexing papers.But what is evidence-based medicine (EBM)? First and foremost, EBM is a set of strategies designed to help the clinician keep up-to-date and to base his clinical decision making on the best available external evidence. EBM has been espoused by policymakers, purchasers and others — and, although the approach is open to misuse by these groups as a cost-cutting exercise, there are refreshing signs that they will be able to use the approach to help produce real improvements in patient care. However, the essential focus of EBM is on assisting doctors and other clinicians make decisions about individual patients. The steps involved in EBM include: a precise definition of the clinical problem (a crucial first step — in medical practice it will usually include making a diagnosis), an efficient search for the best available evidence, critical appraisal of the evidence and integration of the research findings with clinical expertise. Finally, the clinician assesses the outcome of the process and continues to improve his EBM skills.

ELSA – A Method for Medical Knowledge Acquisition and Processing to Aid Medical Reasoning

1986 ◽  
Vol 25 (02) ◽  
pp. 79-86 ◽  
Author(s):  
J. Ruszkowski
Keyword(s):  
Clinical Data ◽  
Clinical Decision Making ◽  
Medical Knowledge ◽  
Order Relation ◽  
Clinical Problem ◽  
Clinical Decision ◽  
Medical Problem ◽  
Method Performance ◽  
Practical Applications ◽  
Medical Reasoning

SummaryExperts’ Lattice-Structured Acquirements (ELSA) is a method of medical experts’ knowledge management which aims at aiding clinical problem solving by various ways and forms, from simple procedures of clinical data evaluation to computer-aided consultation and teaching systems in all fields of medicine. The concept of the ELSA method is based upon the assumption of the relational nature of medical reasoning and clinical decision making in man. Furthermore, there are some reasons to judge that physicians rather use qualitative clinical data or quantitative ones converted into qualitative ones in their clinical thinking. Two stages of method performance have been described: First, the data acquisition concerned with total decomposition of a medical problem to as simple as possible questions to the experts and, second, the composition procedure to be applied to the knowledge structures obtained as experts’ answers. The paper deals with algorithms of how to record and check experts’ knowledge data obtained according to ELSA rules and how to use them for setting up an order relation in diagnostic hypotheses set according to the syndrome of symptoms and signs considered. Some practical applications and evaluations of the method are mentioned.

scholarly journals GLIOBLASTOMA MULTIFORME: A META-ANALYSIS OF DRIVER GENES, CURRENT DIAGNOSIS, AND TUMOR HETEROGENEITY

2020 ◽  
Author(s):  
Gabriel Emilio Herrera-Oropeza ◽  
Carla Angulo-Rojo ◽  
Santos Alberto Gástelum-López ◽  
Alfredo Varela-Echavarría ◽  
Maribel Hernández-Rosales ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Molecular Subtype ◽  
Cell Model ◽  
Meta Analysis ◽  
Adult Population ◽  
Young Patients ◽  
Clinical Decision ◽  
Significant Heterogeneity ◽  
Driver Genes ◽  
Molecular Events

AbstractGlioblastoma (GBM) is the most aggressive and common brain cancer in adults with the lowest life expectancy. The current neuro-oncology practice has incorporated genes involved in key molecular events that drive GBM tumorigenesis as biomarkers to guide diagnosis and design treatment. This study summarizes findings describing the significant heterogeneity of GBM at the transcriptional and genomic levels, emphasizing eighteen driver genes with clinical relevance. A pattern was identified fitting the stem cell model for GBM ontogenesis, with an up-regulation profile for MGMT and down-regulation for ATRX, H3F3A, TP53, and EGFR in the mesenchymal subtype. We also detected overexpression of EGFR, NES, VIM, and TP53 in the classical subtype and of MKi67 and OLIG2 genes in the proneural subtype. In keeping with this, we found a panel of nine biomarkers with a strong potential to determine the GBM molecular subtype. A unique distribution of somatic mutations was found for the young and adult population, particularly for genes related to DNA repair and chromatin remodeling, highlighting ATRX, MGMT, and IDH1. Our results also revealed that highly lesioned genes undergo differential regulation with particular biological pathways for young patients. This meta-analysis will help delineate future strategies related to the use of these molecular markers for clinical decision-making in the medical routine.

Suicidal Behaviors and their Clinical Management in Adults

2018 ◽  
Author(s):  
Sneha R Lopes ◽  
Jess G Fiedorowicz
Keyword(s):  
Clinical Judgment ◽  
Suicide Risk ◽  
Stressful Life Events ◽  
Clinical Decision Making ◽  
Adult Population ◽  
Clinical Decision ◽  
The United States ◽  
Rigorous Evaluation ◽  
Effective Manner ◽  
Patients At Risk

Suicide consistently remains among the top 10 leading causes of death in the adult population. In the past decade, suicide rates have steadily increased in the United States, underscoring the need for expanding clinical and public health efforts. This review aims to provide the psychiatrist with the necessary tools to assess suicide risk and manage accordingly. This review outlines a conceptual structure for the assessment of suicide risk. Some common suicide risk factors include a previous suicide attempt, psychiatric illness, and stressful life events. With an assessment derived from rigorous evaluation, an appropriately individualized plan is formulated for the patient. The clinician ultimately exercises a clinical judgment, regarding the level of risk and appropriate management, taking into account a multitude of factors. Although suicide is not entirely preventable, clinicians can train themselves to effectively identify patients at risk of suicide and intervene in a timely, effective manner. This review contains 3 figures, 4 tables, and 111 references. Key Words: clinical decision-making, clozapine, epidemiology, interventions, interview skills, lithium, pharmacotherapy, psychotherapy, risk assessment, screening, suicide

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