Background Despite the excellent prognosis of Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) stage I, type I endometrial cancers, a substantial number of patients experience recurrence and die from this disease. We analyzed the value of immunohistochemical L1CAM determination to predict clinical outcome. Methods We conducted a retrospective multicenter cohort study to determine expression of L1CAM by immunohistochemistry in 1021 endometrial cancer specimens. The Kaplan–Meier method and Cox proportional hazard model were applied for survival and multivariable analyses. A machine-learning approach was used to validate variables for predicting recurrence and death. Results Of 1021 included cancers, 17.7% were rated L1CAM-positive. Of these L1CAM-positive cancers, 51.4% recurred during follow-up compared with 2.9% L1CAM-negative cancers. Patients bearing L1CAM-positive cancers had poorer disease-free and overall survival (two-sided Log-rank P < .001). Multivariable analyses revealed an increase in the likelihood of recurrence (hazard ratio [HR] = 16.33; 95% confidence interval [CI] = 10.55 to 25.28) and death (HR = 15.01; 95% CI = 9.28 to 24.26). In the L1CAM-negative cancers FIGO stage I subdivision, grading and risk assessment were irrelevant for predicting disease-free and overall survival. The prognostic relevance of these parameters was related strictly to L1CAM positivity. A classification and regression decision tree (CRT)identified L1CAM as the best variable for predicting recurrence (sensitivity = 0.74; specificity = 0.91) and death (sensitivity = 0.77; specificity = 0.89). Conclusions To our knowledge, L1CAM has been shown to be the best-ever published prognostic factor in FIGO stage I, type I endometrial cancers and shows clear superiority over the standardly used multifactor risk score. L1CAM expression in type I cancers indicates the need for adjuvant treatment. This adhesion molecule might serve as a treatment target for the fully humanized anti-L1CAM antibody currently under development for clinical use.

Introduction: There is a substantial amount of evidence from animal models that early brain injury (EBI) may play an important role for secondary brain injury after aneurysmal subarachnoid hemorrhage (aSAH). Cerebral microdialysis (CMD) allows online measurement of brain metabolites, including the pro-inflammatory cytokine interleukin-6 (IL-6) and matrix metalloproteinase-9 (MMP-9), which is indicative for disruption of the blood-brain barrier. Methods: Twenty-six consecutive poor-grade aSAH patients with multimodal neuromonitoring were analyzed for brain hemodynamic and metabolic changes, including CMD-IL-6 and CMD-MMP-9 levels. Statistical analysis was performed by using a generalized estimating equation with an autoregressive function. Results: The baseline cerebral metabolic profile revealed brain metabolic distress and an excitatory response which improved over the following 5 days (P <0.001). Brain tissue hypoxia (brain tissue oxygen tension of less than 20 mm Hg) was common (more than 60% of patients) in the first 24 hours of neuromonitoring and improved thereafter (P <0.05). Baseline CMD-IL-6 and CMD-MMP-9 levels were elevated in all patients (median = 4,059 pg/mL, interquartile range (IQR) = 1,316 to 12,456 pg/mL and median = 851 pg/mL, IQR = 98 to 25,860 pg/mL) and significantly decreased over days (P <0.05). A higher pro-inflammatory response was associated with the development of delayed cerebral ischemia (P = 0.04), whereas admission disease severity and early brain tissue hypoxia were associated with higher CMD-MMP-9 levels (P <0.03). Brain metabolic distress and increased IL-6 levels were associated with poor functional outcome (modified Rankin Scale of more than 3, P ≤0.01). All models were adjusted for probe location, aneurysm securing procedure, and disease severity as appropriate. Conclusions: Multimodal neuromonitoring techniques allow insight into pathophysiologic changes in the early phase after aSAH. The results may be used as endpoints for future interventions targeting EBI in poor-grade aSAH patients.

Background: Computerized physician order entry systems (CPOE) can reduce the number of medication errors and adverse drug events (ADEs) in healthcare institutions. Unfortunately, they tend to produce a large number of partly irrelevant alerts, in turn leading to alert overload and causing alert fatigue. The objective of this work is to identify factors that can be used to prioritize and present alerts depending on the 'context' of a clinical situation. Methods: We used a combination of literature searches and expert interviews to identify and validate the possible context factors. The internal validation of the context factors was performed by calculating the inter-rater agreement of two researcher's classification of 33 relevant articles. Results: We developed a context model containing 20 factors. We grouped these context factors into three categories: characteristics of the patient or case (e.g. clinical status of the patient); characteristics of the organizational unit or user (e.g. professional experience of the user); and alert characteristics (e.g. severity of the effect). The internal validation resulted in nearly perfect agreement (Cohen's Kappa value of 0.97). Conclusion: To our knowledge, this is the first structured attempt to develop a comprehensive context model for prioritizing drug safety alerts in CPOE systems. The outcome of this work can be used to develop future tailored drug safety alerting in CPOE systems.

While Nursing Informatics competencies seem essential for the daily work of nurses, they are not formally integrated into nursing education in Austria, Germany and Switzerland, nor are there any national educational recommendations. The aim of this paper is to show how such recommendations can be developed, what competency areas are most relevant in the three countries and how the recommendations can be implemented in practice. To this end, a triple iterative procedure was proposed and applied starting with national health informatics recommendations for other professionals, matching and enriching these findings with topics from the international literature and finally validating them in an expert survey with 87 experts and in focus group sessions. Out of the 24 compiled competency areas, the relevance ratings of the following four recommended areas achieved values above 90%: nursing documentation (including terminologies), principles of nursing informatics, data protection and security, and quality assurance and quality management. As there were no significant differences between the three countries, these findings laid the foundation of the DACH Recommendations of Nursing Informatics as joint German (D), Austrian (A), and Swiss (CH) recommendations in Nursing Informatics. The methodology proposed has been utilized internationally, which demonstrates the added value of this study also outside the confines of Austria, Germany, Switzerland.

Summary: Background: Progress in the medical sciences, together with related technologies, in the past has led to higher specialization and has created a strong need to exchange health information across institutional borders. The concept of electronic health records (EHR) was introduced to fulfill these needs. Remarkably, many EHR introduction projects ran into trouble, not least because they lacked the acceptance of EHR among physicians. Negative emotions, such as anxiety and fear due to a lack of information, may cause change barriers and hamper physicians’ acceptance of such projects. Objectives: The goal of this study was to gain deeper insight into the negative emotions related to the intended implementation of a mandatory national electronic health record system (called ELGA) in Austria among physicians in private practice. Methods: Qualitative, problem-centered interviews were conducted with eight physicians in private practice in the capital region of Tyrol. The methods of qualitative content analysis were used to analyze the data. Results: Three hundred and twenty-eight pas sages in the interviews were selected, annotated, and paraphrased. These passages were assigned to 139 different primary categories. Finally, 18 main categories in the form of statements were derived. They were correlated and a theoretical model was formed to explain the genesis of the detected fears and anxiety related to the ELGA project. The results show that the physicians feel uninformed and snubbed. They fear unknown changes, increased costs, as well as workload and surveillance without obtaining any advantages from using electronic health records in their daily practice. Conclusion: Impartial information campaigns that are tailored to the physicians’ needs and questions as along with a comprehensive cost-benefit analysis could benefit the physicians’ opinion of EHRs.

Objectives: To analyze the attitude of physicians towards alerting in CPOE systems in different hospitals in different countries, addressing various organizational and technical settings and the view of physicians not currently using a CPOE. Methods: A cross-sectional quantitative and qualitative questionnaire survey. We invited 2,600 physicians in eleven hospitals from nine countries to participate. Eight of the hospitals had different CPOE systems in use, and three of the participating hospitals were not using a CPOE system. Results: 1,018 physicians participated. The general attitude of the physicians towards CPOE alerting is positive and is found to be mostly independent of the country, the specific organizational settings in the hospitals and their personal experience with CPOE systems. Both quantitative and qualitative results show that the majority of the physicians, both CPOE-users and non-users, appreciate the benefits of alerting in CPOE systems on medication safety. However, alerting should be better adapted to the clinical context and make use of more sophisticated ways to present alert information. The vast majority of physicians agree that additional information regarding interactions is useful on demand. Around half of the respondents see possible alert overload as a major problem; in this regard, physicians in hospitals with sophisticated alerting strategies show partly better attitude scores. Conclusions: Our results indicate that the way alerting information is presented to the physicians may play a role in their general attitude towards alerting, and that hospitals with a sophisticated alerting strategy with less interruptive alerts tend towards more positive attitudes. This aspect needs to be further investigated in future studies. ^* Supplementary material published on our website www.methods-online.com