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Extended telemedical consultation using Arden Syntax based decision support, hypertext and WWW technique
Linköpings universitet, Institutionen för medicinsk teknik, Medicinsk informatik. Linköpings universitet, Tekniska högskolan.
Linköpings universitet, Institutionen för klinisk och experimentell medicin, Infektionsmedicin. Linköpings universitet, Hälsouniversitetet.
Linköpings universitet, Institutionen för medicinsk teknik, Medicinsk informatik. Linköpings universitet, Tekniska högskolan.
Linköpings universitet, Institutionen för medicinsk teknik, Medicinsk informatik. Linköpings universitet, Tekniska högskolan.
Visa övriga samt affilieringar
1997 (Engelska)Ingår i: Methods of Information in Medicine, ISSN 0026-1270, Vol. 36, nr 2, s. 108-114Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

There is an obvious need for geographic distribution of expert knowledge among several health care units without increasing the cost of on-site expertise in locations where health care is provided. This paper describes the design of a knowledge-based decision-support system for extended consultation in clinical medicine. The system is based on Arden Syntax for Medical Logic Modules and hypertext using World Wide Web technology. It provides advice and explanations regarding the given advice. The explanations are presented in a hypertext format allowing the user to browse related information and to verify the relevance of the given advice. The system is intended to be used in a closed local network. With special precautions regarding issues of safety and patient security, the system can be used over wider areas such as in rural medicine. A prototype has been developed in the field of clinical microbiology and infectious diseases regarding infective endocarditis.

Ort, förlag, år, upplaga, sidor
1997. Vol. 36, nr 2, s. 108-114
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
URN: urn:nbn:se:liu:diva-13333PubMedID: 9242006OAI: oai:DiVA.org:liu-13333DiVA, id: diva2:18506
Tillgänglig från: 2008-06-18 Skapad: 2008-06-18 Senast uppdaterad: 2017-12-13
Ingår i avhandling
1. Infective Endocarditis: aspects of pathophysiology, epidemiology, management and prognosis
Öppna denna publikation i ny flik eller fönster >>Infective Endocarditis: aspects of pathophysiology, epidemiology, management and prognosis
2008 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Infective endocarditis (IE) is a rare but complex disease that is fatal if untreated. With a modern combination of antimicrobial therapy and heart valve surgery, mortality is still 10-20 %. The structure of the endocarditis vegetation impedes the penetration of phagocytic cells such as monocytes and granulocytes. This leads to high bacterial counts inside the vegetation and the need for long treatment courses with a combination of intravenously administered bactericidal antibiotics.

The aim of this thesis was to study the changes in epidemiology, management, and mortality at our hospital between 1980 and 2001, and to identify prognostic factors associated with mortality. To assess the issue of referral bias, differences between referred episodes and episodes from our local community were studied. Additional aims were to study the occurrence of the pro-chemotactic cytokines IL-8 and TNF-α in heart valves and vegetations during the active phase of IE, and to study the effect of the glycopeptide antibiotic vancomycin in dense staphylococcal cultures in vitro. As it is a rare and complex disease, management of IE is usually complicated for non-specialists. For this reason a computerised decision support system for IE was developed and evaluated.

Between 1980 and 2001, the occurrence of Staphylococcus aureus IE and the use of early heart valve surgery increased significantly, regardless of whether the episodes were referred or of local origin. Glycopeptide antibiotics, mainly vancomycin, were used more frequently, especially among referred patients. Referred patients were younger, predominantly male, had more complications, and received surgical treatment more often than patients from our local community. The reason for the lower frequency of female patients in the referral cohort cannot be explained by more comorbidity or fewer complications. The differences between referred and local episodes seen in our study highlight the need for assessment and adjustment for referral bias in IE studies (Paper I).

In six patients who needed early heart valve surgery, the largest numbers of IL-8-containing cells, and the greatest amount of inflammation, were seen in patients with short preoperative antimicrobial treatment courses. No such relationships were seen with respect to TNF-α-containing cells. The IL-8-containing cells and the inflammatory cells were predominantly scattered in the heart valve stroma or in the margin of the vegetation (Paper II). The primary effect of IL-8 is to stimulate chemotaxis of polymorphonuclear neutrophil granulocytes. This indicates that there is no deficiency of IL-8 in the area close to the vegetation as a cause of the localised agranulocytosis often present inside the vegetation.

Our study revealed a need for computerised decision support systems (DSSs) in the field of IE, but to be used in clinical practice these DSSs need be part of knowledge bases covering larger domains (Paper IV). Some of our initial ideas described in Paper III, especially the use of Internet technology and the combination of rule-based advice and explanatory hypertext, will probably be included in these knowledge bases.

In vitro, there is a rapid reduction of free vancomycin in broth containing dense staphylococcal cultures. Consequently, there is a simultaneous increase in broth MICs, particularly in high inocula, which is not caused by a development of resistance (Paper V). These findings need further evaluation in vivo, but indicate that the dosing regimen of vancomycin is of particular importance in staphylococcal infections with dense inocula, e.g. infective endocarditis.

Diabetes mellitus and moderate to severe heart failure were independent risk factors for 6-month mortality in left-sided, Duke definite IE episodes, regardless of referral or local origin of the episodes. Early heart valve surgery had a positive impact on the 6-month mortality in the referral cohort of episodes, which may be due to referral bias (Paper VI).

Ort, förlag, år, upplaga, sidor
Linköping University Electronic Press, 2008. s. 42
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1017
Nyckelord
epidemiology, Infective endocarditis (IE), heart valve surgery, monocytes, granulocytes, staphylococ
Nationell ämneskategori
Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi
Identifikatorer
urn:nbn:se:liu:diva-12274 (URN)978-91-85895-83-0 (ISBN)
Disputation
2008-05-14, Elsa Brändströmsalen, Campus US, Linköpings universitet, Linköping, 13:00 (Engelska)
Opponent
Handledare
Tillgänglig från: 2008-06-18 Skapad: 2008-06-18 Senast uppdaterad: 2020-03-29
2. Aspects of the use of medical decision-support systems: the role of context in decision support
Öppna denna publikation i ny flik eller fönster >>Aspects of the use of medical decision-support systems: the role of context in decision support
2001 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

There is a great need today for distribution of medical information. The amount of information is growing quickly, and information that could potentially influence clinical practice fails to reach health care professionals. The supply of information to health care has from the start been the main goal of medical informatics. However, with very few exceptions, the systems developed to support the formalization and distribution of medical knowledge, i.e. decision-support or expert systems, have not attained clinical use. Thus, since there is an unsatisfied need for information and the methods developed so far have been successful to only a limited extent, it is important to gain insight into both how decision-support systems are used and which of their properties may influence the usability.

This thesis describes aspects of the use of medical decision-support systems by looking at two prototype implementations of such systems. The prototypes concerned bacterial endocarditis and urinary tract infections respectively. The first prototype system was evaluated and a theory of the use of the system was developed, thereby leading to further theorization and the development of a new system design. The goal of the system designs was to facilitate the interpretation and assessment of generated advice. This kind of support was realized by applying an expertext system model, a model that supports triangulation of decision-support methods and information sources. To organize the information in an expertext environment, a common terminological domain model was used in the second system design. In the theorization, a special focus was on contextual aspects of system use. Differences between knowledge provider and end-user contexts concerning the use of decision-support systems were analyzed. The importance of support for multi-perspective interpretation of system output such as is present in our system designs was confirmed.

Ort, förlag, år, upplaga, sidor
Linköping: UNIT, 2001. s. 45
Serie
Linköping Studies in Science and Technology. Dissertations, ISSN 0345-7524 ; 662
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:liu:diva-29007 (URN)14240 (Lokalt ID)91-7219-896-6 (ISBN)14240 (Arkivnummer)14240 (OAI)
Disputation
2001-01-09, Sal 1, Farmakologen, Plan 8, Universitetssjukhuset, Linköping, 09:00 (Svenska)
Tillgänglig från: 2009-10-09 Skapad: 2009-10-09 Senast uppdaterad: 2013-02-19

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Karlsson, DanielEkdahl, ChristerWigertz, OveShahsavar, NosratGill, HansForsum, Urban

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