%0 Journal Article %J Br J Gen Pract %D 2010 %T Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis %A McNally, Maggie %A Curtain, James %A O'Brien, K %A Dimitrov, B %A Fahey, T %K Family Practice %K Great Britain %K Humans %K Pneumonia %K Prognosis %K Risk Assessment %K Severity of Illness Index %K Validation Studies as Topic %X BACKGROUND: The CRB-65 score is a clinical prediction rule that grades the severity of community-acquired pneumonia in terms of 30-day mortality. AIM: The study sought to validate CRB-65 and assess its clinical value in community and hospital settings. DESIGN OF STUDY: Systematic review and meta-analysis of validation studies of CRB-65. METHOD: Medline (1966 to June 2009), Embase (1988 to November 2008), British Nursing Index (BNI) and PsychINFO were searched, using a diagnostic accuracy search filter combined with subject-specific terms. The derived (index) rule was used as a predictive model and applied to all validation studies. Comparison was made between the observed and predicted number of deaths stratified by risk group (low, intermediate, and high) and setting of care (community or hospital). Pooled results are presented as risk ratios (RRs) in terms of over-prediction (RR>1) or under-prediction (RR<1) of 30-day mortality. RESULTS: Fourteen validation studies totalling 397 875 patients are included. CRB-65 performs well in hospitalised patients, particularly in those classified as intermediate (RR 0.91, 95% confidence interval [CI] = 0.71 to 1.17) or high risk (RR 1.01, 95% CI = 0.87 to 1.16). In community settings, CRB-65 over-predicts the probability of 30-day mortality across all strata of predicted risk, low (RR 9.41, 95% CI = 1.75 to 50.66), intermediate (RR 4.84, 95% CI = 2.61 to 8.69), and high (RR 1.58, 95% CI = 0.59 to 4.19). CONCLUSION: CRB-65 performs well in stratifying severity of pneumonia and resultant 30-day mortality in hospital settings. In community settings, CRB-65 appears to over-predict the probability of 30-day mortality across all strata of predicted risk. Caution is needed when applying CRB-65 to patients in general practice. %B Br J Gen Pract %V 60 %P e423-33 %8 2010 Oct %G eng %U http://bjgp.org/content/60/579/e423 %N 579 %R 10.3399/bjgp10X532422 %0 Journal Article %J Thromb Haemost %D 2011 %T Validation of the CHADS2 clinical prediction rule to predict ischaemic stroke. A systematic review and meta-analysis %A Keogh, C %A Wallace, E %A Dillon, C %A Dimitrov, B %A Fahey, T %K Atrial Fibrillation %K Humans %K Myocardial Ischemia %K Practice Guidelines as Topic %K Predictive Value of Tests %K Prognosis %K Quality Assurance, Health Care %K Research Design %K Risk %K Sensitivity and Specificity %K Stroke %X The CHADS2 predicts annual risk of ischaemic stroke in non-valvular atrial fibrillation. This systematic review and meta-analysis aims to determine the predictive value of CHADS2. The literature was systematically searched from 2001 to October 2010. Data was pooled and analysed using discrimination and calibration statistical measures, using a random effects model. Eight data sets (n = 2815) were included. The diagnostic accuracy suggested a cut-point of ≥ 1 has higher sensitivity (92%) than specificity (12%) and a cut-point of ≥ 4 has higher specificity (96%) than sensitivity (33%). Lower summary estimates were observed for cut-points ≥ 2 (sensitivity 79%, specificity 42%) and ≥ 3 (specificity 77%, sensitivity 50%). There was insufficient data to analyse cut-points ≥ 5 or ≥ 6. Moderate pooled c statistic values were identified for the classic (0.63, 95% CI 0.52-0.75) and revised (0.60, 95% CI 0.43-0.72) view of stratification of the CHADS2. Calibration analysis indicated no significant difference between the predicted and observed strokes across the three risk strata for the classic or revised view. All results were associated with high heterogeneity, and conclusions should be made cautiously. In conclusion, the pooled c statistic and calibration analysis suggests minimal clinical utility of both the classic and revised view of the CHADS2 in predicting ischaemic stroke across all risk strata. Due to high heterogeneity across studies and low event rates across all risk strata, the results should be interpreted cautiously. Further validation of CHADS2 should perhaps be undertaken, given the methodological differences between many of the available validation studies and the original CHADS2 derivation study. %B Thromb Haemost %V 106 %P 528-38 %8 2011 Sep %G eng %U http://th.schattauer.de/en/contents/archive/issue/1439/manuscript/16384.html %N 3 %R 10.1160/TH11-02-0061 %0 Journal Article %J J Am Geriatr Soc %D 2013 %T A systematic review of the probability of repeated admission score in community-dwelling adults %A Wallace, E %A Hinchey, T %A Dimitrov, B %A Bennett, K %A Fahey, T %A Smith, SM %K Aged %K Aged, 80 and over %K Brazil %K Calibration %K Decision Support Techniques %K Europe %K Female %K Health Care Costs %K Health Services for the Aged %K Humans %K Male %K Mortality %K Patient Readmission %K Probability %K Reproducibility of Results %K Risk Assessment %K Sensitivity and Specificity %K United States %K Validation Studies as Topic %X OBJECTIVES: To perform a systematic review of the Probability of Repeated Admission (Pra) score in community-dwelling adults to assess its performance in a range of validation studies in the community setting. DESIGN: Systematic review and meta-analysis. SETTING: Primary and community care. PARTICIPANTS: Community-dwelling older people. MEASUREMENTS: The primary outcome was hospital admission; secondary outcomes were mortality, hospital days, functional decline, other health service use, and costs. RESULTS: Nine validation studies describing 11 cohorts of individuals aged 65 and older were identified. A metaanalysis of the Pra score in five cohorts (8,843 individuals) with comparable and available data revealed good discrimination performance (summary area under the receiver operating characteristic curve 69.7% (standard error 2.8%)). Pooled specificity was high (96%, 95% confidence interval (CI)=95.8–96.7%), indicating that a Pra score of 0.5 or greater effectively rules in the likelihood of admission, but pooled sensitivity was low (12%, 95% CI=10.5–13.6%). Calibration performance was good, with an overall risk ratio of 1.12 (95% CI=0.89–1.42), indicating that the Pra score reliably predicted hospital admissions. CONCLUSION: The Pra score performs well in predicting hospital admission in community-dwelling adults categorized as high risk according to the score. This tool has clinical and healthcare policy utility in terms of targeting elderly people at highest risk of hospital admission, but the low pooled sensitivity of the score indicates that it is not a reliable way of excluding hospital admission in those stratified as low risk. %B J Am Geriatr Soc %V 61 %P 357-64 %8 2013 Mar %G eng %U http://onlinelibrary.wiley.com/doi/10.1111/jgs.12150/abstract %N 3 %R 10.1111/jgs.12150 %0 Journal Article %J Clinical Epidemiology %D 2015 %T A simplified approach to the pooled analysis of calibration of clinical prediction rules for systematic reviews of validation studies %A Dimitrov, B %A Motterlini, N %A Fahey, T %K clinical prediction rules %K derivation %K Meta-analysis %K primary care %K validation %X Objective: Estimating calibration performance of clinical prediction rules (CPRs) in systematic reviews of validation studies is not possible when predicted values are neither published nor accessible or sufficient or no individual participant or patient data are available. Our aims were to describe a simplified approach for outcomes prediction and calibration assessment and evaluate its functionality and validity. Study design and methods: Methodological study of systematic reviews of validation studies of CPRs: a) ABCD2 rule for prediction of 7 day stroke; and b) CRB-65 rule for prediction of 30 day mortality. Predicted outcomes in a sample validation study were computed by CPR distribution patterns (“derivation model”). As confirmation, a logistic regression model (with derivation study coefficients) was applied to CPR-based dummy variables in the validation study. Meta-analysis of validation studies provided pooled estimates of “predicted:observed” risk ratios (RRs), 95% confidence intervals (CIs), and indexes of heterogeneity (I2) on forest plots (fixed and random effects models), with and without adjustment of intercepts. The above approach was also applied to the CRB-65 rule. Results: Our simplified method, applied to ABCD2 rule in three risk strata (low, 0–3; intermediate, 4–5; high, 6–7 points), indicated that predictions are identical to those computed by univariate, CPR-based logistic regression model. Discrimination was good (c-statistics =0.61–0.82), however, calibration in some studies was low. In such cases with miscalibration, the under-prediction (RRs =0.73–0.91, 95% CIs 0.41–1.48) could be further corrected by intercept adjustment to account for incidence differences. An improvement of both heterogeneities and P-values (Hosmer-Lemeshow goodness-of-fit test) was observed. Better calibration and improved pooled RRs (0.90–1.06), with narrower 95% CIs (0.57–1.41) were achieved. Conclusion: Our results have an immediate clinical implication in situations when predicted outcomes in CPR validation studies are lacking or deficient by describing how such predictions can be obtained by everyone using the derivation study alone, without any need for highly specialized knowledge or sophisticated statistics. %B Clinical Epidemiology %V 7 %P 267-280 %8 04/2015 %G eng %U http://www.dovepress.com/articles.php?article_id=21355 %9 Published Journal Article %& 267 %R http://dx.doi.org/10.2147/CLEP.S67632 %0 Journal Article %J QJM %D 2011 %T The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study %A Crawford, F %A McCowan, Colin %A Dimitrov, B %A Woodburn, J %A Wylie, G H %A Booth, E %A Leese, G P %A Bekker, H L %A Kleijnen, J %A Fahey, T %K Adult %K Aged %K Aged, 80 and over %K Delivery of Health Care %K Diabetes Mellitus, Type 2 %K Diabetic Foot %K Diabetic Neuropathies %K Female %K Humans %K Male %K Mass Screening %K Middle Aged %K Predictive Value of Tests %K Risk Factors %K Scotland %X BACKGROUND: Annual foot checks are recommended in patients with diabetes mellitus (DM) to identify those at risk of foot ulceration. Systematic reviews have found few studies evaluating the predictive value of tests in community-based diabetic populations. AIM: To quantify the predictive value of clinical risk factors in relation to foot ulceration in a community population. METHODS: A cohort of 1192 people with diabetes receiving care in community settings was recruited and a screening procedure, covering symptoms, signs and diagnostic tests was conducted at baseline. At an average 1-year follow-up patients who developed a foot ulcer were identified by an independent blind assessor. Multivariable analysis was performed to identify clinical predictors of foot ulceration. FINDINGS: The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27-2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1-69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9-4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3-2.2). INTERPRETATION: Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations. %B QJM %V 104 %P 403-10 %8 2011 May %G eng %U http://qjmed.oxfordjournals.org/content/104/5/403 %N 5 %R 10.1093/qjmed/hcq227 %0 Journal Article %J J Subst Abuse Treat %D 2011 %T Risk of drug-related mortality during periods of transition in methadone maintenance treatment: a cohort study %A Cousins, G %A Teljeur, C %A Motterlini, N %A McCowan, Colin %A Dimitrov, B %A Fahey, T %K Adolescent %K Adult %K Cohort Studies %K Databases, Factual %K Female %K Humans %K Lung Diseases %K Male %K Medical Records %K Methadone %K Middle Aged %K Opiate Substitution Treatment %K Opioid-Related Disorders %K Patient Dropouts %K Prescriptions %K Risk %K Time Factors %K Young Adult %X This study aims to identify periods of elevated risk of drug-related mortality during methadone maintenance treatment (MMT) in primary care using a cohort of 3,162 Scottish drug users between January 1993 and February 2004. Deaths occurring during treatment or within 3 days after last methadone prescription expired were considered as cases "on treatment." Fatalities occurring 4 days or more after leaving treatment were cases "off treatment." Sixty-four drug-related deaths were identified. The greatest risk of drug-related death was in the first 2 weeks of treatment (adjusted hazard ratio 2.60, 95% confidence interval 1.03-6.56). Risk of drug-related death was lower after the first 30 days following treatment cessation, relative to the first 30 days off treatment. History of psychiatric admission was associated with increased risk of drug-related death in treatment. Increasing numbers of treatment episodes and urine testing were protective. History of psychiatric admission, increasing numbers of urine tests, and coprescriptions of benzodiazepines increased the risk of mortality out of treatment. The risk of drug-related mortality in MMT is elevated during periods of treatment transition, specifically treatment initiation and the first 30 days following treatment dropout or discharge. %B J Subst Abuse Treat %V 41 %P 252-60 %8 2011 Oct %G eng %U http://www.sciencedirect.com/science/article/pii/S0740547211000973 %N 3 %R 10.1016/j.jsat.2011.05.001 %0 Journal Article %J Fam Pract %D 2011 %T Prognostic value of the ABCD² clinical prediction rule: a systematic review and meta-analysis %A Galvin, R %A Geraghty, Colm %A Motterlini, N %A Dimitrov, B %A Fahey, T %K Humans %K Ischemic Attack, Transient %K Predictive Value of Tests %K Risk Assessment %K Risk Factors %K Stroke %K Time Factors %X OBJECTIVE: The purpose of this systematic review with meta-analysis is to determine the predictive value of the ABCD ²at 7 and 90 days across three strata of risk. Background. The risk of stroke after transient ischaemic attack (TIA) is significant. The ABCD ²clinical prediction rule is designed to predict early risk of stroke after TIA. A number of independent validation studies have been conducted since the rule was derived. METHODS: A systematic literature search was conducted to identify studies that validated the ABCD². The derived rule was used as a predictive model and applied to subsequent validation studies. Comparisons were made between observed and predicted number of strokes stratified by risk group: low (0-3 points), moderate (4-5 points) and high (6-7 points). Pooled results are presented as risk ratios (RRs) with 95% confidence intervals (CIs), in terms of over-prediction (RR > 1) or under-prediction (RR < 1) of stroke at 7 and 90 days. RESULTS: We include 16 validation studies. Fourteen studies report 7-day stroke risk (n = 6282, 388 strokes). The ABCD² rule correctly predicts occurrence of stroke at 7 days across all three risk strata: low [RR 0.86, 95% CI (0.47-1.58), I² = 16%], moderate [RR 0.99, 95% CI (0.67-1.47), I² = 68%] and high [RR 0.84, 95% CI (0.6-1.19), I² = 46%]. Eleven studies report 90-day stroke risk (n = 6304). There is a non-significant trend towards over-prediction of stroke in all risk categories at 90 days. There are 426 strokes observed in contrast to a predicted 626 strokes. As the trichotomized ABCD² score increases, the risk of stroke increases (P < 0.01). There is no evidence of publication bias in these studies (P > 0.05). CONCLUSION: The ABCD² is a useful CPR, particularly in relation to 7-day risk of stroke. %B Fam Pract %V 28 %P 366-76 %8 2011 Aug %G eng %U http://fampra.oxfordjournals.org/content/28/4/366 %N 4 %R 10.1093/fampra/cmr008 %0 Journal Article %J BMC Med %D 2011 %T Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score %A Aalbers, Jolien %A O'Brien, K %A Chan, Wai-Sun %A Falk, G %A Teljeur, C %A Dimitrov, B %A Fahey, T %K Adult %K Diagnosis, Differential %K Humans %K Pharyngitis %K Predictive Value of Tests %K Primary Health Care %K Streptococcal Infections %K Streptococcus pyogenes %X BACKGROUND: Stratifying patients with a sore throat into the probability of having an underlying bacterial or viral cause may be helpful in targeting antibiotic treatment. We sought to assess the diagnostic accuracy of signs and symptoms and validate a clinical prediction rule (CPR), the Centor score, for predicting group A β-haemolytic streptococcal (GABHS) pharyngitis in adults (> 14 years of age) presenting with sore throat symptoms. METHODS: A systematic literature search was performed up to July 2010. Studies that assessed the diagnostic accuracy of signs and symptoms and/or validated the Centor score were included. For the analysis of the diagnostic accuracy of signs and symptoms and the Centor score, studies were combined using a bivariate random effects model, while for the calibration analysis of the Centor score, a random effects model was used. RESULTS: A total of 21 studies incorporating 4,839 patients were included in the meta-analysis on diagnostic accuracy of signs and symptoms. The results were heterogeneous and suggest that individual signs and symptoms generate only small shifts in post-test probability (range positive likelihood ratio (+LR) 1.45-2.33, -LR 0.54-0.72). As a decision rule for considering antibiotic prescribing (score ≥ 3), the Centor score has reasonable specificity (0.82, 95% CI 0.72 to 0.88) and a post-test probability of 12% to 40% based on a prior prevalence of 5% to 20%. Pooled calibration shows no significant difference between the numbers of patients predicted and observed to have GABHS pharyngitis across strata of Centor score (0-1 risk ratio (RR) 0.72, 95% CI 0.49 to 1.06; 2-3 RR 0.93, 95% CI 0.73 to 1.17; 4 RR 1.14, 95% CI 0.95 to 1.37). CONCLUSIONS: Individual signs and symptoms are not powerful enough to discriminate GABHS pharyngitis from other types of sore throat. The Centor score is a well calibrated CPR for estimating the probability of GABHS pharyngitis. The Centor score can enhance appropriate prescribing of antibiotics, but should be used with caution in low prevalence settings of GABHS pharyngitis such as primary care. %B BMC Med %V 9 %P 67 %8 2011 %G eng %U http://www.biomedcentral.com/1741-7015/9/67 %R 10.1186/1741-7015-9-67 %0 Journal Article %J BMC Fam Pract %D 2010 %T Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs %A Giesen, Leonie G M %A Cousins, G %A Dimitrov, B %A Van de Laar, F A %A Fahey, T %K Adult %K Bayes Theorem %K Female %K Humans %K Predictive Value of Tests %K Urinalysis %K Urinary Tract Infections %X BACKGROUND: Acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (10(2) or 10(3) or 10(5) CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making. METHODS: Searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking.Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ≥ 10(2) CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model. RESULTS: Sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ≥ 10(2) CFU/ml; 55.4% at ≥ 10(3) CFU/ml and 44.8% at ≥ 10(2) CFU/ml ≥ 10(5) CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ≥ 10(2) CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ≥ 10(2) CFU/ml and 67.4% at ≥ 10(3) CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ≥ 10(2) CFU/ml and ≥ 10(3) CFU/ml. CONCLUSIONS: Individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites. %B BMC Fam Pract %V 11 %P 78 %8 2010 %G eng %U http://www.biomedcentral.com/1471-2296/11/78 %R 10.1186/1471-2296-11-78 %0 Journal Article %J J Clin Epidemiol %D 2011 %T Optimized retrieval of primary care clinical prediction rules from MEDLINE to establish a Web-based register %A Keogh, C %A Wallace, E %A O'Brien, K %A Murphy, Paul J %A Teljeur, C %A McGrath, Brid %A Smith, SM %A Niall Doherty %A Dimitrov, B %A Fahey, T %K Abstracting and Indexing as Topic %K Databases, Bibliographic %K Humans %K Information Storage and Retrieval %K MEDLINE %K Primary Health Care %K Sensitivity and Specificity %K Subject Headings %X OBJECTIVES: Identifying clinical prediction rules (CPRs) for primary care from electronic databases is difficult. This study aims to identify a search filter to optimize retrieval of these to establish a register of CPRs for the Cochrane Primary Health Care field. STUDY DESIGN AND SETTING: Thirty primary care journals were manually searched for CPRs. This was compared with electronic search filters using alternative methodologies: (1) textword searching; (2) proximity searching; (3) inclusion terms using specific phrases and truncation; (4) exclusion terms; and (5) combinations of methodologies. RESULTS: We manually searched 6,344 articles, revealing 41 CPRs. Across the 45 search filters, sensitivities ranged from 12% to 98%, whereas specificities ranged from 43% to 100%. There was generally a trade-off between the sensitivity and specificity of each filter (i.e., the number of CPRs and total number of articles retrieved). Combining textword searching with the inclusion terms (using specific phrases) resulted in the highest sensitivity (98%) but lower specificity (59%) than other methods. The associated precision (2%) and accuracy (60%) were also low. CONCLUSION: The novel use of combining textword searching with inclusion terms was considered the most appropriate for updating a register of primary care CPRs where sensitivity has to be optimized. %B J Clin Epidemiol %V 64 %P 848-60 %8 2011 Aug %G eng %U http://www.sciencedirect.com/science/article/pii/S0895435610004233 %N 8 %R 10.1016/j.jclinepi.2010.11.011 %0 Journal Article %J BMC Research Notes %D 2014 %T Long-term risk of stroke after transient ischaemic attack: a hospital-based validation of the ABCD2 rule %A Galvin, R %A Atanassova, P %A Motterlini, N %A Fahey, T %A Dimitrov, B %K Stroke; Transient ischaemic attack; Risk prediction; ABCD2 rule; Bulgaria %X Abstract Background The ABCD2 clinical prediction rule is a seven point summation of clinical factors independently predictive of stroke risk. The purpose of this cohort study is to validate the ABCD2 rule in a Bulgarian hospital up to three years after TIA. Methods All consecutive admissions to an emergency department with symptoms of a first TIA were included. Baseline data and clinical examinations including the ABCD2 scores were documented by neurologists. Discrimination and calibration performance was examined using ABCD2 cut-off scores of ≥3, ≥4 and ≥5 points, consistent with the international guidelines. The Hosmer-Lemeshow test was used to examine calibration between the observed and expected outcomes as predicted by ABCD2 score within the logistic regression analysis. Results Eighty-nine patients were enrolled to the study with a mean age of 63 years (+/- 12 years). Fifty-nine percent (n = 53) of the study population was male. Seven strokes (7 · 8%) occurred within the first year and six further strokes within the three-year follow-up period. There was no incident of stroke within the first 90 days after TIA. The rule demonstrated good predictive (OR = 1 · 58, 95% CI 1 · 09-2 · 29) and discriminative performance (AUCROC = 0 · 72, 95% CI 0 · 58-0 · 86), as well as a moderate calibration performance at three years. Conclusion This validation of the ABCD2 rule in a Bulgarian hospital demonstrates that the rule has good predictive and discriminative performance at three years. The ABCD2 is quick to administer and may serve as a useful tool to assist clinicians in the long-term management of individuals with TIA. %B BMC Research Notes %V 7 %8 05/2014 %G eng %U http://www.biomedcentral.com/1756-0500/7/281 %9 Published Journal Article %R 10.1186/1756-0500-7-281 %0 Journal Article %J Semin Arthritis Rheum %D 2011 %T Injection of botulinum toxin for treatment of chronic lateral epicondylitis: systematic review and meta-analysis %A Galvin, R %A Callaghan, Claire %A Chan, Wai-Sun %A Dimitrov, B %A Fahey, T %K Botulinum Toxins, Type A %K Chronic Disease %K Databases, Bibliographic %K Finger Injuries %K Humans %K Injections, Intramuscular %K Movement %K Neuromuscular Agents %K Outpatients %K Pain %K Randomized Controlled Trials as Topic %K Tennis Elbow %K Treatment Outcome %X In this article in Seminars in Arthritis and Rheumatism, Kalichman and coworkers examine the impact of the botulinum toxin injections in the management of lateral epicondylitis ( 1). We would like to add to the findings of this systematic review in 2 ways: first, we use a different method of pooling the data that allows us to present the findings in a clinically meaningful manner. Second, we also examine 2 randomized controlled trials (RCTs) that compare an active comparator to BoNT-A injections ( 2 and 3). We have summarized the 6 trials in Table 1 %B Semin Arthritis Rheum %V 40 %P 585-7 %8 2011 Jun %G eng %U http://www.sciencedirect.com/science/article/pii/S0049017211000151 %N 6 %R 10.1016/j.semarthrit.2011.01.003 %0 Journal Article %J Ann of Fam Med %D 2014 %T Developing an International Register of Clinical Prediction Rules for Use in Primary Care: A Descriptive Analysis %A Keogh, C %A Wallace, E %A O'Brien, K %A Galvin, R %A Smith, SM %A Lewis, Cliona %A Cummins, Anthony %A Cousins, G %A Dimitrov, B %A Fahey, T %K clinical decision support systems %K clinical prediction rule %K decision aid %K decision making %K primary care %K score card %X Abstract PURPOSE We describe the methodology used to create a register of clinical prediction rules relevant to primary care. We also summarize the rules included in the register according to various characteristics. METHODS To identify relevant articles, we searched the MEDLINE database (PubMed) for the years 1980 to 2009 and supplemented the results with searches of secondary sources (books on clinical prediction rules) and personal resources (eg, experts in the field). The rules described in relevant articles were classified according to their clinical domain, the stage of development, and the clinical setting in which they were studied. RESULTS Our search identified clinical prediction rules reported between 1965 and 2009. The largest share of rules (37.2%) were retrieved from PubMed. The number of published rules increased substantially over the study decades. We included 745 articles in the register; many contained more than 1 clinical prediction rule study (eg, both a derivation study and a validation study), resulting in 989 individual studies. In all, 434 unique rules had gone through derivation; however, only 54.8% had been validated and merely 2.8% had undergone analysis of their impact on either the process or outcome of clinical care. The rules most commonly pertained to cardiovascular disease, respiratory, and musculoskeletal conditions. They had most often been studied in the primary care or emergency department settings. CONCLUSIONS Many clinical prediction rules have been derived, but only about half have been validated and few have been assessed for clinical impact. This lack of thorough evaluation for many rules makes it difficult to retrieve and identify those that are ready for use at the point of patient care. We plan to develop an international web-based register of clinical prediction rules and computer-based clinical decision support systems. %B Ann of Fam Med %V 12 %P 359-366 %8 07/2014 %G eng %U http://www.ncbi.nlm.nih.gov/pubmed/25024245 %N 4 %9 Published Article Journal %& 359 %R 10.1370/afm.1640 %0 Journal Article %J BMC Med Inform Decis Mak %D 2011 %T Developing an electronic health record (EHR) for methadone treatment recording and decision support %A Xiao, Liang %A Cousins, G %A Courtney, Brenda %A Hederman, Lucy %A Fahey, T %A Dimitrov, B %K Decision Support Techniques %K Drug Therapy, Computer-Assisted %K Electronic Health Records %K Episode of Care %K Humans %K Medical Record Linkage %K Methadone %K Practice Guidelines as Topic %K Semantics %K Systematized Nomenclature of Medicine %K User-Computer Interface %X BACKGROUND: In this paper, we give an overview of methadone treatment in Ireland and outline the rationale for designing an electronic health record (EHR) with extensibility, interoperability and decision support functionality. Incorporating several international standards, a conceptual model applying a problem orientated approach in a hierarchical structure has been proposed for building the EHR. METHODS: A set of archetypes has been designed in line with the current best practice and clinical guidelines which guide the information-gathering process. A web-based data entry system has been implemented, incorporating elements of the paper-based prescription form, while at the same time facilitating the decision support function. RESULTS: The use of archetypes was found to capture the ever changing requirements in the healthcare domain and externalises them in constrained data structures. The solution is extensible enabling the EHR to cover medicine management in general as per the programme of the HRB Centre for Primary Care Research. CONCLUSIONS: The data collected via this Irish system can be aggregated into a larger dataset, if necessary, for analysis and evidence-gathering, since we adopted the openEHR standard. It will be later extended to include the functionalities of prescribing drugs other than methadone along with the research agenda at the HRB Centre for Primary Care Research in Ireland. %B BMC Med Inform Decis Mak %V 11 %P 5 %8 2011 %G eng %U http://www.biomedcentral.com/1472-6947/11/5 %R 10.1186/1472-6947-11-5 %0 Journal Article %J BMC Med %D 2011 %T The Alvarado score for predicting acute appendicitis: a systematic review %A Ohle, Robert %A O'Reilly, Fran %A O'Brien, K %A Fahey, T %A Dimitrov, B %K Appendicitis %K Humans %K Predictive Value of Tests %K Severity of Illness Index %X BACKGROUND: The Alvarado score can be used to stratify patients with symptoms of suspected appendicitis; the validity of the score in certain patient groups and at different cut points is still unclear. The aim of this study was to assess the discrimination (diagnostic accuracy) and calibration performance of the Alvarado score. METHODS: A systematic search of validation studies in Medline, Embase, DARE and The Cochrane library was performed up to April 2011. We assessed the diagnostic accuracy of the score at the two cut-off points: score of 5 (1 to 4 vs. 5 to 10) and score of 7 (1 to 6 vs. 7 to 10). Calibration was analysed across low (1 to 4), intermediate (5 to 6) and high (7 to 10) risk strata. The analysis focused on three sub-groups: men, women and children. RESULTS: Forty-two studies were included in the review. In terms of diagnostic accuracy, the cut-point of 5 was good at 'ruling out' admission for appendicitis (sensitivity 99% overall, 96% men, 99% woman, 99% children). At the cut-point of 7, recommended for 'ruling in' appendicitis and progression to surgery, the score performed poorly in each subgroup (specificity overall 81%, men 57%, woman 73%, children 76%). The Alvarado score is well calibrated in men across all risk strata (low RR 1.06, 95% CI 0.87 to 1.28; intermediate 1.09, 0.86 to 1.37 and high 1.02, 0.97 to 1.08). The score over-predicts the probability of appendicitis in children in the intermediate and high risk groups and in women across all risk strata. CONCLUSIONS: The Alvarado score is a useful diagnostic 'rule out' score at a cut point of 5 for all patient groups. The score is well calibrated in men, inconsistent in children and over-predicts the probability of appendicitis in women across all strata of risk. %B BMC Med %V 9 %P 139 %8 2011 %G eng %U http://www.biomedcentral.com/1741-7015/9/139 %R 10.1186/1741-7015-9-139 %0 Generic %D 2011 %T Variations in General Practice prescribing patterns in Ireland: preliminary result. Faculty of Public Health Medicine Winter Scientific Meeting 2011, RCPI, 14 December 2011, Dublin %A Motterlini, N %A Dimitrov, B %A Bradley, MC %A Bennett, K %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Motterlini_Practice%20Variation_Poster%20WSM2011.pdf %0 Generic %D 2009 %T A systematic review of the diagnostic accuracy of signs and symptoms and the validation of the Centor score in predicting group A haemolytic streptococcal pharyngitis in adults in primary care. 12th Annual Scientific Meeting of the Association of Universi %A O'Brien, K %A Aalbers, Jolien %A Chan, Wai-Sun %A Dimitrov, B %A Falk, G %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/AalbersJ/Strep%20throat%20poster%20audgpi%20v2.ppt %0 Generic %D 2012 %T Prognostic value of the ABCD2 clinical prediction rule – a prospective cohort study. SAPC Conference 2012, 2-4 October 2012, Glasgow, Scotland %A Galvin, R %A Atanassova, P %A Motterlini, N %A Fahey, T %A Dimitrov, B %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Galvin_ABCD2 cohort.ppt %0 Generic %D 2010 %T Predictive accuracy of the ABCD² clinical prediction rule: A systematic review and preliminary analysis of pooled data. IHF Stroke Conference 2010, March 26 2010, Dublin, Ireland %A Geraghty, Colm %A Galvin, R %A Motterlini, N %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/posters/ACBD2.pdf %0 Generic %D 2010 %T Predicting stroke in non-rheumatic atrial fibrillation: A systematic review of validation of the CHADS2 clinical prediction rule. RCSI Research Day, 7th April 2010, Dublin, Ireland %A Wallace, E %A Keogh, C %A Dillion, C %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/posters/CHADS2.pdf %0 Generic %D 2010 %T Predicting stroke in adults with non-rheumatic atrial fibrillation: A systematic review of the validation of CHADS2 Clinical Prediction Rule (preliminary results). 6th Annual Cochrane in Ireland Conference, 28 January 2010, School of Nursing, Dublin City %A Wallace, E %A Dillon, C %A Keogh, C %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/WallaceE/CHDADS2%20Cochrane%20poster.ppt %0 Generic %D 2012 %T New Simplified approach to the pooled analysis of calibration of clinical predicition rules for systematic reviews of validation studies. 32nd Conference on Applied Statistics in Ireland 2012. 16-18 May 2012, ISA, Ballymascanlon H H, Dundalk, Co Louth %A Dimitrov, B %A Motterlini, N %A Fahey, T %G eng %U http://hrbcentreprimarycare.ie/ppt/SIMPLIFIED%20APPROACH%20TO%20CALIBRATION.pdf %0 Generic %D 2012 %T New simplified approach to the pooled analysis of calibration of clinical prediction rules for systematic reviews of validation studies. Poster at the Population Health USRG Launch Meeting, 8 Nov 2012, University of Southampton, Southampton, UK %A Dimitrov, B %A Motterlini, N %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Dimitrov B et al 2012 Poster - NEW SIMPL APPROACH - PHUSRG-v3.pdf %0 Generic %D 2010 %T Botulinum Toxin injection in the treatment of tennis elbow – a systematic and meta-analysis: a preliminary study. 13th Annual Scientific Meeting of the Association of University Departments of General Practice in Ireland, 19 March 2010, RCSI, Dublin, Irel %A Callaghan, Claire %A Galvin, R %A Chan, Wai-Sun %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/posters/TE.pdf %0 Generic %D 2010 %T Systematic review on the diagnostic accuracy of signs and symptoms predicting UTI in women. 13th Annual Scientific Meeting of the Association of University Departments of General Practice in Ireland, 19 March 2010, RCSI, Dublin, Ireland %A Giesen, Leonie G M %A Cousins, G %A Dimitrov, B %A Van de Laar, F A %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/GiesenL/GC_LG_AUDGPI_presentation_final.ppt %0 Generic %D 2010 %T Systematic review of validation studies of the Alvarado Clinical Prediction Rule for Appendicitis. 39th Annual Scientific Meeting of the SAPC, 7- 9 July 2010, University of East Anglia, Norwich, UK %A Cummins, Anthony %A Ohle, Robert %A O'Reilly, Fran %A O'Brien, K %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/AlvaradoSAPC2010.pptx %0 Generic %D 2009 %T A Systematic Review of the diagnostic accuracy of signs and symptoms and the validation of the Centor score in predicting group A β-haemolytic streptococcal pharyngitis in adults in primary care. SAPC Conference, 8-10 July 2009, University of Dundee, UK %A O'Brien, K %A Aalbers, Jolien %A Chan, Wai-Sun %A Dimitrov, B %A Falk, G %A Teljeur, C %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/AalbersJ/Presentation%20Sore%20Throat%2015%20Jan.ppt %0 Generic %D 2010 %T Risk of stroke following transient ischaemic attack: The ABCD2 CPR. The Society for Social Medicine, 6-8 September 2010, Belfast %A Galvin, R %A Geraghty, Colm %A Motterlini, N %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/ABCD2Sept10.ppt %0 Generic %D 2010 %T Risk of overdose mortality during the initial two weeks after entering or re-entering methadone treatment in Scotland: Retrospective cohort study. The Society for Social Medicine, 6-8 September 2010, Belfast %A Cousins, G %A Teljeur, C %A Motterlini, N %A McCowan, Colin %A Dimitrov, B %A Fahey, T %G eng %0 Generic %D 2010 %T Register of Clinical Prediction Rules, Methodological Quality assessment and Implementation Strategies. 39th Annual Scientific Meeting of the SAPC, 7- 9 July 2010, University of East Anglia, Norwich %A Wallace, E %A Keogh, C %A Smith, SM %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Emma%20Wallace%20SAPC%20presentation.pdf %0 Generic %D 2010 %T Register of Clinical Prediction Rules, methodological quality assessment and implementation strategies. European General Practice Research Network conference. October 14-17th, 2010, Zurich, Switzerland %A Wallace, E %A Keogh, C %A Smith, SM %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Emma%20Wallace%20EGPRN%20presentation.ppt %0 Generic %D 2013 %T Prognostic value of the ABCD2 clinical prediction rule – a hospital based validation study. Irish Heart Foundation (IHF) Annual Stroke Study Day, 12 April 2013, Dublin %A Galvin, R %A Atanassova, P %A Motterlini, N %A Fahey, T %A Dimitrov, B %G eng %0 Generic %D 2010 %T Prediction Stroke in Adults with Non-rheumatic Atrail Fibrillation: Validating the CHADS2 Rule. 39th Annual Scientific Meeting of the SAPC, 7- 9 July 2010, University of East Anglia, Norwich, UK %A Keogh, C %A Wallace, E %A Dimitrov, B %A Dillon, C %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/KeoghSAPC.pptx %0 Generic %D 2009 %T Predicting severity of pneumonia in general practice: a meta-analysis of the CRB-65 criteria. SAPC Conference, 8-10 July 2009, University of Dundee & St. Andrews on behalf of the Scottish School of Primary Care, Dundee, UK %A McNally, Maggie %A Curtain, James %A O'Brien, K %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Maggie/SAPC%20Presentation.ppt %0 Generic %D 2009 %T Predicting severity of pneumonia in general practice: a meta-analysis of the CRB-65 criteria. 12th Annual Scientific Meeting of the Association of University Departments of General Practice in Ireland, 27 February 2009 RCSI, Dublin, Ireland %A McNally, Maggie %A Curtain, James %A O'Brien, K %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/Maggie/SAPC%20Presentation.ppt %0 Generic %D 2010 %T Predicting risk of stroke following TIA: A systematic review of the validation of ABCD2 Clinical Prediction Rule. 39th Annual Scientific Meeting of the SAPC, 7- 9 July 2010, University of East Anglia, Norwich %A Galvin, R %A Geraghty, Colm %A Motterlini, N %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/ABCD2SAPCJuly10.ppt %0 Generic %D 2011 %T Knowledge representation in TRANSFoRm. AMIA CDSS workshop, 24 October 2011, Washington DC, USA %A Corrigan, D %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/AMIA%20Presentation.ppt %0 Generic %D 2010 %T The effectiveness of botulinum toxin injection in the management of lateral epicondylitis: a systematic review. Irish Society of Chartered Physiotherapists conference 12 – 13 November 2010. HRB Centre for Primary Care Research., Dublin %A Galvin, R %A Callaghan, Claire %A Chan, Wai-Sun %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/HISI_RCSI_Pres.ppt %0 Generic %D 2010 %T Clinical Prediction Rules as a basis for Clinical Decision Support. 15th Annual Health Informatics Society of Ireland Conference, 18 November 2010, Dublin. %A Corrigan, D %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/HISI_OpenEHR_Pres.ppt %0 Generic %D 2011 %T Aspects of the TRANSFoRm Project. HIQA conference, 7 July 2011, Dublin %A Corrigan, D %A Ohmann, C %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/ppt/TRANSFORM_HIQA_Final.ppt %0 Generic %D 2010 %T Systematic review of the diagnostic accuracy of signs & symptoms and validation of the Centor Score in predicting group A b-haemolytic streptococcal pharyngitis in adults in Primary Care. International Forum for Diagnostic, HRB Centre, Dublin %A O'Brien, K %A Aalbers, Jolien %A Chan, Wai-Sun %A Dimitrov, B %A Teljeur, C %A Falk, G %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T A Systematic Review of the CHADS2 Score for Predicting Stroke Risk in Patients with Non-rheumatic Atrial Fibrillation. International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre, Dublin %A Keogh, C %A Wallace, E %A Dillon, C %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T A Systematic Review of the Alvarado Score in predicting acute Appendicitis. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research, Dublin %A Ohle, Robert %A O'Reilly, Fran %A O'Brien, K %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T Risk of stroke following transient ischaemic attack: the ABCD² CPR. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research, Dublin %A Galvin, R %A Geraghty, Colm %A Motterlini, N %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T Patient Safety and Clinical Prediction Rules. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research, Dublin %A Corrigan, D %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T Overview of utilization and examples of CDSSs and eCPRs. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research %A Courtney, Brenda %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T An overview of primary care models: suitability for provision of e-services. Lecture, Division of Population Health Sciences Academic Seminar Series, RCSI, 15 April 2010, Dublin %A Dimitrov, B %G eng %0 Generic %D 2010 %T New validation method. Clinical Prediction Rules – International Working Group, 29-30 September 2010, Oxford, UK %A Dimitrov, B %G eng %U http://www.hrbcentreprimarycare.ie/ppt/New%20Validation%20Method%20-%20Borislav%20Dimitrov%20-%20OK.ppt %0 Generic %D 2010 %T Methodological Quality of Clinical Prediction Rules. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research %A Wallace, E %A Smith, SM %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T International Register and Clinical Domains in Primary Care. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research, Dublin %A Keogh, C %A Wallace, E %A O'Brien, K %A Murphy, Paul J %A Teljeur, C %A McGrath, Brid %A Smith, SM %A Niall Doherty %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T Indices of performances of CPRs. Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research %A Motterlini, N %A Dimitrov, B %A Fahey, T %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Generic %D 2010 %T Computer-based Clinical Decision Support Systems (CDSSs). Clinical Prediction Rules – International Forum for Diagnostic and Prognostic Strategies in Primary Care, 4 June 2010, HRB Centre for Primary Care Research, Dublin %A Dimitrov, B %G eng %U http://www.hrbcentreprimarycare.ie/default.aspx?ID=124 %0 Conference Proceedings %B In: Proceedings of the Transforming Government Workshop "Enabling Citizen Participation, Social Inclusion & Democracy through Electronic Systems & Processes" (tGov) 2010, March 18-19 2010, Brunel University, London, UK %D 2010 %T Primary health care models and suitability for provision of e-services: an overview %A Dimitrov, B %A Fahey, T %B In: Proceedings of the Transforming Government Workshop "Enabling Citizen Participation, Social Inclusion & Democracy through Electronic Systems & Processes" (tGov) 2010, March 18-19 2010, Brunel University, London, UK %G eng %0 Conference Paper %B ITI 2009 31st International Conference on Information Technology Interfaces (ITI Book Series) %D 2009 %T Towards knowledge sharing and patient privacy in a clinical decision support system %A Xiao, Liang %A Hu, B %A Hederman, Lucy %A Lewis P %A Dimitrov, B %A Fahey, T %B ITI 2009 31st International Conference on Information Technology Interfaces (ITI Book Series) %G eng %0 Conference Paper %B IEEE 14th International Conference on e-Health Networking, Applications and Services (Healthcom) %D 2012 %T Developing a rule-driven clinical decision support system with an extensive and adaptative architecture %A Xiao, Liang %A Cousins, G %A Fahey, T %A Dimitrov, B %A Hederman, Lucy %B IEEE 14th International Conference on e-Health Networking, Applications and Services (Healthcom) %I IEEE %C Beijing, China %8 10/2012 %@ 978-1-4577-2039-0 %G eng %U http://ieeexplore.ieee.org/xpl/login.jsp?tp=&arnumber=6379416&url=http%3A%2F%2Fieeexplore.ieee.org%2Fstamp%2Fstamp.jsp%3Ftp%3D%26arnumber%3D6379416