scholarly journals Decision-making in the diagnosis of tuberculous meningitis

2020 ◽  
Vol 5 ◽  
pp. 11
Author(s):  
Tom H. Boyles ◽  
Lutgarde Lynen ◽  
James A. Seddon ◽  
Keyword(s):  
Decision Making ◽  
Tuberculous Meningitis ◽  
Threshold Model ◽  
Rapid Test ◽  
Bayes Theorem ◽  
Treatment Decisions ◽  
Nucleic Acid Amplification ◽  
Test Results ◽  
Diagnostic Strategies ◽  
Test Probability

Tuberculous meningitis (TBM) is the most devastating form of tuberculosis (TB) but diagnosis is difficult and delays in initiating therapy increase mortality. All currently available tests are imperfect; culture of Mycobacterium tuberculosis from the cerebrospinal fluid (CSF) is considered the most accurate test but is often negative, even when disease is present, and takes too long to be useful for immediate decision making. Rapid tests that are frequently used are conventional Ziehl–Neelsen staining and nucleic acid amplification tests such as Xpert MTB/RIF and Xpert MTB/RIF Ultra. While positive results will often confirm the diagnosis, negative tests frequently provide insufficient evidence to withhold therapy. The conventional diagnostic approach is to determine the probability of TBM using experience and intuition, based on prevalence of TB, history, examination, analysis of basic blood and CSF parameters, imaging, and rapid test results. Treatment decisions may therefore be both variable and inaccurate, depend on the experience of the clinician, and requests for tests may be inappropriate. In this article we discuss the use of Bayes’ theorem and the threshold model of decision making as ways to improve testing and treatment decisions in TBM. Bayes’ theorem describes the process of converting the pre-test probability of disease to the post-test probability based on test results and the threshold model guides clinicians to make rational test and treatment decisions. We discuss the advantages and limitations of using these methods and suggest that new diagnostic strategies should ultimately be tested in randomised trials.

scholarly journals 754. A Two-step Testing Algorithm for Hospital-onset Clostridioides difficile Infection (CDI) Reduces Prescribing of C. difficile (CD) Therapy but Its Ability to Guide Treatment Decisions Remains Unclear

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S474-S474
Author(s):  
Mackenzie Dolan ◽  
Heather Cox ◽  
Cirle A Warren ◽  
Costi Sifri ◽  
Melinda Poulter ◽  
...  
Keyword(s):  
Decision Support Tool ◽  
Treatment Decisions ◽  
Adverse Outcomes ◽  
Nucleic Acid Amplification ◽  
Test Results ◽  
Patient Death ◽  
Support Tool ◽  
Clostridioides Difficile ◽  
Days Of Therapy ◽  
Testing Algorithm

Abstract Background Determining true CDI versus CD colonization through CD testing is a continuing challenge. A previously introduced decision support tool at UVA Health significantly reduced inappropriate testing without adverse outcomes. More recently, our methodology changed from nucleic acid amplification test (NAAT) alone to an initial NAAT followed by ELISA for toxin to improve specificity. The purpose of this analysis was to assess provider interpretation of test results, using targeted CD therapy as a surrogate. Methods This single-center, retrospective study evaluated all patients with a positive NAAT (Cepheid Xpert® C. difficile) on day 4 or later of hospitalization following 2-step algorithm implementation from Feb 2020 through Feb 2021. Toxin negative (TOX-) test results (C. DIFF QUIK CHEK COMPLETE®) were accompanied by a comment that discordance may represent colonization or CDI and to consider ID consult. The proportion of toxin positive (TOX+) versus TOX- patients receiving ≥ 1 dose of CD therapy served as the primary outcome with partial courses considered < 10 days. Clinical outcomes were also compared. Results Ninety patients with NAAT+ results were included, of whom 58 (64%) were TOX-. Thirty-two (100%) TOX+ (median days of therapy [IQR] = 14 [11-17]) versus 51 (88%) TOX- patients (median days of therapy [IQR] = 11 [7-14]) received CD therapy (p=0.04). Treatment decisions were guided by ID physicians for 32 (63%) TOX- patients; ID recommendations to discontinue CD therapy were followed in 2 out of 9 (22%) cases. TOX- patients received partial therapy due to patient death (n=5), presumptive colonization (n=3), and provider error (n=1). Of TOX- patients receiving partial or no treatment, there were no CDI-related adverse outcomes during the admission. CDI-related colectomy occurred in 2 (6%) and 1 (2%) TOX+ and TOX- patients, respectively. Five in-hospital deaths with CDI as a contributing factor occurred in the TOX+ group. Conclusion Adoption of a 2-step NAAT plus toxin testing algorithm for hospital-onset CDI reduced the frequency with which TOX- patients received CD therapy but the vast majority were still treated. Most providers considered a positive NAAT indicative of CDI, regardless of TOX status. Disclosures All Authors: No reported disclosures

scholarly journals Genomic screening and genomic diagnostic testing—two very different kettles of fish

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Leslie G. Biesecker
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Diagnostic Testing ◽  
Clinical Decision ◽  
Bayes Theorem ◽  
Genomic Testing ◽  
Test Results ◽  
Correct Interpretation ◽  
Genomic Test ◽  
Genomic Screening

AbstractGenomic testing can be misunderstood as being determinative, when in reality it is the same as all other tests and context is essential for its correct interpretation. Two hypothetical cases of testing for Marfan syndrome demonstrate how clinicians should contextualize genomic test results and the implementation of Bayes theorem in clinical decision-making.

scholarly journals Decision Making for Treatment After ACL Injury From an Orthopaedic Surgeon and Patient Perspective: Results From the NACOX Study

2021 ◽  
Vol 9 (4) ◽  
pp. 232596712110050
Author(s):  
Hanna Tigerstrand Grevnerts ◽  
Sofi Sonesson ◽  
Håkan Gauffin ◽  
Clare L. Ardern ◽  
Anders Stålman ◽  
...  
Keyword(s):  
Decision Making ◽  
High Activity ◽  
Treatment Decision ◽  
Acl Injury ◽  
Treatment Decisions ◽  
Activity Level ◽  
Knee Instability ◽  
Acl Injuries ◽  
Patient Reported ◽  
And Function

Background: In the treatment of anterior cruciate ligament (ACL) injuries, there is little evidence of when and why a decision for ACL reconstruction (ACLR) or nonoperative treatment (non-ACLR) is made. Purpose: To (1) describe the key characteristics of ACL injury treatment decisions and (2) compare patient-reported knee instability, function, and preinjury activity level between patients with non-ACLR and ACLR treatment decisions. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 216 patients with acute ACL injury were evaluated during the first year after injury. The treatment decision was non-ACLR in 73 patients and ACLR in 143. Reasons guiding treatment decision were obtained from medical charts and questionnaires to patients and orthopaedic surgeons. Patient-reported instability and function were obtained via questionnaires and compared between patients with non-ACLR and ACLR treatment decisions. The ACLR treatment group was classified retrospectively by decision phase: acute phase (decision made between injury day and 31 days after injury), subacute phase (decision made between 32 days and up to 5 months after injury), and late phase (decision made 5-12 months after injury). Data were evaluated using descriptive statistics, and group comparisons were made using parametric or nonparametric tests as appropriate. Results: The main reasons for a non-ACLR treatment decision were no knee instability and no problems with knee function. The main reasons for an ACLR treatment decision were high activity demands and knee instability. Patients in the non-ACLR group were significantly older ( P = .031) and had a lower preinjury activity level than did those in the acute-phase ( P < .01) and subacute-phase ( P = .006) ACLR decision groups. There were no differences in patient-reported instability and function between treatment decision groups at baseline, 4 weeks after injury, or 3 months after injury. Conclusion: Activity demands, not patient-reported knee instability, may be the most important factor in the decision-making process for treatment after ACL injury. We suggest a decision-making algorithm for patients with ACL injuries and no high activity demands; waiting for >3 months can help distinguish those who need surgical intervention from those who can undergo nonoperative management. Registration: NCT02931084 ( ClinicalTrials.gov identifier).

scholarly journals Influenza colloidal gold method and blood routine tests combination for rapid diagnosis of influenza: a decision tree-based analysis

2021 ◽  
Vol 31 (1) ◽  
Author(s):  
Xiaoguang Li ◽  
Jing Chen ◽  
Fei Lin ◽  
Wei Wang ◽  
Jie Xu ◽  
...  
Keyword(s):  
Decision Tree ◽  
Predictive Value ◽  
Colloidal Gold ◽  
Influenza A ◽  
Clinical Manifestations ◽  
Rapid Test ◽  
Test Results ◽  
Tree Model ◽  
Routine Blood ◽  
Test Result

AbstractRapid influenza diagnosis can facilitate targeted treatment and reduce antibiotic misuse. However, diagnosis efficacy remains unclear. This study examined the efficacy of a colloidal gold rapid test for rapid influenza diagnosis. Clinical characteristics of 520 patients with influenza-like illness presenting at a fever outpatient clinic during two influenza seasons (2017–2018; 2018–2019) were evaluated. The clinical manifestations and results of routine blood, colloidal gold, and nucleic acid tests were used to construct a decision tree with three layers, nine nodes, and five terminal nodes. The combined positive predictive value of a positive colloidal gold test result and monocyte level within 10.95–12.55% was 88.2%. The combined negative predictive value of a negative colloidal gold test result and white blood cell count > 9.075 × 109/L was 84.9%. The decision-tree model showed the satisfactory accuracy of an early influenza diagnosis based on colloidal gold and routine blood test results.

scholarly journals Cancer Patients: Their Desire for Information and Participation in Treatment Decisions

1989 ◽  
Vol 82 (5) ◽  
pp. 260-263 ◽  
Author(s):  
H J Sutherland ◽  
H A Llewellyn-Thomas ◽  
G A Lockwood ◽  
D L Tritchler ◽  
J E Till
Keyword(s):  
Decision Making ◽  
Cancer Patients ◽  
Decision Maker ◽  
Treatment Decisions ◽  
Autonomous Decision ◽  
Disclosure Of Information ◽  
Participation In Decision Making ◽  
Psychological Autonomy ◽  
The Relationship

The relationship between cancer patients’ desire for information and their preference for participation in decision making has been examined. Approximately 77% of the 52 patients reported that they had participated in decision making to the extent that they wished, while most of the remaining 23% would have preferred an opportunity to have greater input. Although many of the patients actively sought information, a majority preferred the physician to assume the role of the primary decision maker. Ethically, the disclosure of information has been assumed to be necessary for autonomous decision making. Nevertheless, the results of this study indicate that patients may actively seek information to satisfy an as yet unidentified aspect of psychological autonomy that does not necessarily include participation in decision making.

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