http://hdl.handle.net/2027.42/78562 2013-05-18T09:01:06Z http://hdl.handle.net/2027.42/78267 Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain Trafton, Jodie A; Martins, Susana B; Michel, Martha C; Wang, Dan; Tu, Samson W; Clark, David J; Elliott, Janette; Vucic, Brigit; Balt, Steve; Clark, Michael E; Sintek, Charles D; Rosenberg, Jack; Daniels, Denise; Goldstein, Mary K Abstract Background Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients. Methods Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools. Results The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools. Conclusions Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations. 2010-04-12T00:00:00Z http://hdl.handle.net/2027.42/75020 Management of Intrathecal Catheter-Tip Inflammatory Masses: A Consensus Statement Hassenbusch, Samuel; Burchiel, Kim; Coffey, Robert J.; Cousins, Michael J.; Deer, Tim; Hahn, Marc B.; Pen, Stuart Du; Follett, Kenneth A.; Krames, Elliot; Rogers, James N.; Sagher, Oren; Staats, Peter S.; Wallace, Mark; Willis, Kenneth Dean In a companion article, we synthesized current clinical and preclinical data to formulate hypotheses about the etiology of drug administration catheter-tip inflammatory masses. In this article, we communicate our recommendations for the detection, treatment, mitigation, and prevention of such masses. Methods. We reviewed published and unpublished case reports and our own experiences to find methods to diagnose and treat catheter-tip inflammatory masses in a manner that minimized adverse neurological sequelae. We also formulated hypotheses about theoretical ways to mitigate, and possibly, prevent the formation of such masses. Results. Human cases have occurred only in patients with chronic pain who received intrathecal opioid drugs, alone or mixed with other drugs, or in patients who received agents that were not labeled for long-term intrathecal use. Most patients had noncancer pain owing to their large representation among the population with implanted pumps. Such patients also had a longer life expectancy and exposure to intrathecal drugs, and they received higher daily doses than patients with cancer pain. Clues to diagnosis included the loss of analgesic drug effects accompanied by new, gradually progressive neurological symptoms and signs. When a mass was diagnosed before it filled the spinal canal or before it caused severe neurological symptoms, open surgery to remove the mass often was not required. Anecdotal reports and the authors' experiences suggest that cessation of drug administration through the affected catheter was followed by shrinkage or disappearance of the mass over a period of 2-5 months. Conclusions. Attentive follow-up and maintenance of an index of suspicion should permit timely diagnosis, minimally invasive treatment, and avoidance of neurological injury from catheter-tip inflammatory masses. Whenever it is feasible, positioning the catheter in the lumbar thecal sac and/or keeping the daily intrathecal opioid dose as low as possible for as long possible may mitigate the seriousness, and perhaps, reduce the incidence of such inflammatory masses. 2002-12-01T00:00:00Z http://hdl.handle.net/2027.42/74261 Housework and the Wages of Young, Middle-Aged, and Older Workers Keith, Kristen; Malone, Paula 2005-04-01T00:00:00Z http://hdl.handle.net/2027.42/74074 Comparative evaluation of the efficacy and safety of two doses of terbinafine (500 and 1000 mg day −1 ) in the treatment of cutaneous or lymphocutaneous sporotrichosis Chapman, S. W.; Pappas, P.; Kauffmann, C.; Smith, E. B.; Dietze, R.; Tiraboschi-Foss, N.; Restrepo, A.; Bustamante, A. B.; Opper, C.; Emady-Azar, S.; Bakshi, R. 2004-02-01T00:00:00Z