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Data de sfârșit:

septembrie 10, 2015

Electronic records with decision support help optimize emergency care

The timely administration of a clot-dissolving treatment for emergency department patients with acute ischemic stroke nearly doubled following the introduction of new technology that enabled electronic order entry and offered care-decision support for physicians, according to a study published today in the Annals of Emergency Medicine.

The study was conducted during the staged implementation of computerized physician order entry when integrated into electronic health records across 16 Kaiser Permanente Northern California medical centers from 2007 to 2012. After implementation, emergency department stroke guidelines were made available to physicians using an electronic template, known as an „order set.” Order sets are designed to provide standardized laboratory, radiographic and drug ordering, as well as information to help guide doctors in making clinical decisions.

„This study demonstrates that computerized physician order entry generally – and an order set embedded with decision support specifically – can facilitate the delivery of time-sensitive interventions for stroke while minimizing errors,” said lead author Dustin Ballard, MD, an emergency medicine physician at the Kaiser Permanente San Rafael (California) Medical Center and an adjunct researcher at the Kaiser Permanente Division of Research. „In this case, the investigation showed that these tools can safely lead to more frequent administration of medication to thin blood and break up blood clots in the brain, a treatment that has been associated with better neurological recovery after stroke.”

Stroke is a major cause of death and a leading cause of serious long-term disability in the United States. Ischemic stroke, the most common type, is caused by a clot obstructing the flow of blood and oxygen to the brain, which can result in the death of brain cells. Consequently, time is of the essence in assessment and emergency treatment.

„While the technology is not likely to be solely responsible for the improved outcomes observed in this study, it may represent a proxy measure for optimum care for certain patients, in particular those for whom the speed of initiating therapy, the completeness of information available to the clinician, and the intensity of inpatient care make a real difference in short-term outcomes,” added co-author David Vinson, MD, an emergency medicine physician at the Kaiser Permanente Roseville (California) Medical Center.

A systematic approach to the acute management of patients with ischemic stroke – including the timely administration of intravenous tissue plasminogen activator (or IV tPA) for eligible patients – can help avoid complications and improve outcomes. IV tPA helps to thin the blood and dissolve clots, with the goal of restoring blood flow through blocked arteries in the brain. Emergency department evaluation of patients with suspected stroke is focused on rapidly assessing eligibility for time-sensitive interventions such as IV tPA, which has been shown to improve neurological outcomes for acute ischemic stroke.

Of the 10,081 patients examined during the study period, 6,686 (66.3 percent) were treated in medical centers after computerized physician order entry had been implemented. IV tPA was administered in the emergency department to 8.9 percent of these patients, compared to 3.3 percent of patients in emergency departments at medical centers without the new technology – more than doubling the rate of IV tPA administration. When the stroke order set was employed in combination with the computerized physician order entry, IV tPA administration increased to 12.7 percent – a nearly three-fold increase. Even after accounting for variable factors, these differences held steady.

Together, Drs. Ballard and Vinson are co-founders of the Clinical Research in Emergency Services and Treatments (CREST) Network, a group of emergency medicine physician-researchers affiliated with the Kaiser Permanente Division of Research.

„Ultimately, we see the order set itself as optimizing the confluence of two separate processes – a robust computerized physician order entry that integrates care across many providers and locations while limiting errors of omission, combined with a quality initiative that has identified disease-specific best practices and guidelines,” Dr. Ballard wrote. „We believe that our findings represent a dawning era of electronic health records, one that blends decision support and best practices.”

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The study shows patients received recommended and proven therapy safely and more consistently; © panthermedia.net/Arne Trautmann
The study shows patients received recommended and proven therapy safely and more consistently; © panthermedia.net/Arne Trautmann
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Higher risk of death at the weekend

Patients admitted to hospital at the weekend are more likely to be sicker and have a higher risk of death, compared with those admitted during the week, finds an analysis published in The BMJ.

The analysis was carried out as a collaboration between University Hospital Birmingham NHS Foundation Trusts and University College London, and included Sir Bruce Keogh, National Medical Director of NHS England. It examined the effect of hospital admission day on death rates across NHS England hospitals for 2013-2014.

The results confirm findings from an analysis they undertook for 2009-2010.

In the latest analysis, the authors found that around 11,000 more people die each year within 30 days of admission to hospital on Friday, Saturday, Sunday, or Monday compared with other days of the week (Tuesday, Wednesday, Thursday).

This suggests a generalized „weekend effect” which can be partly explained by the reduced support services that start from late Friday through the weekend, leading to disruption on Monday morning, say the authors. Patients already in hospital over the weekend do not have an increased risk of death.

These results remained the same even when taking into account the severity of illness.

The authors caution that it is not possible to show that this excess number of deaths could have been prevented, adding that to do so would be „rash and misleading.”

Nevertheless, they say the number is „not otherwise ignorable” and „we need to determine exactly which services need to be improved at the weekend to tackle the increased risk of mortality.”

They also looked at patient characteristics, length of hospital stay, and time to death.

An average of 2.7 million patients was admitted to hospital on each weekday, while an average of 1.2 million patients was admitted on a Saturday and 1 million patients admitted on a Sunday.

Saturday and Sunday admissions were more likely to be emergencies, 50 percent and 65 percent respectively, than on weekdays (29 percent) and length of stay was also higher for patients admitted on a Saturday and Sunday.

A higher proportion of patients admitted on a Saturday and Sunday had diagnoses that placed them in the highest risk of death category, 24.6 percent and 29.2 percent respectively, compared with less than 20 percent of weekday admissions.

The debate on seven day working was reignited following health secretary Jeremy Hunt’s recent call for hospital doctors to work at weekends to improve quality of care and reduce deaths.

But an accompanying feature article by Helen Crump at the Nuffield Trust says it is not clear how or to what extent investment in seven day services will reduce weekend deaths, and that the costs may outweigh any benefits.
She also warns that, unless overall staffing levels increase, ramping up services at the weekend „will leave a gap in the hospital’s weekday rota, with potentially serious consequences across other services.”

In a linked editorial, Paul Aylin, from Imperial College London, suggests more research is needed to determine the „complex” relation between staffing levels and services, and patient safety. He says promised changes to how the NHS provides weekend and out of hours care „will be an ideal opportunity to evaluate their impact on the weekend effect.”

Seven day working has also been a central part of negotiations between the government and doctors about proposed changes to the standard contract for NHS consultants. Hunt announced that the government would remove a clause in the contract that allowed doctors to opt out of non-emergency work at weekends. But figures obtained from freedom of information requests by BMJ Careers show that just 1 percent of consultants have opted out of non-emergency weekend work.

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Fewer patients are admitted at weekends, but are more likely to be sicker and have a higher risk of death from Friday through until Monday; © panthermedia.net/Suphatthra China
Fewer patients are admitted at weekends, but are more likely to be sicker and have a higher risk of death from Friday through until Monday; © panthermedia.net/Suphatthra China

Personalized medicine needs accurate classification of tumors

If cancer patients are to receive optimal treatment, clinicians must have an accurate histologic classification of the tumor and know its genetic characteristics, said William D. Travis, M.D., attending thoracic pathologist, Department of Pathology, at Memorial Sloan Kettering Cancer Center in New York City.

Travis said the pathology and oncology professions made a big step towards this goal with the release of 2015 WHO Classification of Tumors of the Lung, Pleura, Thymus and Heart.

„WHO Classifications represent a pathologic and genetic classification and grading of human tumors designed to be accepted and used worldwide. They provide standard criteria for pathology diagnosis, clinical practice, cancer registration, epidemiologic studies, clinical trials and cancer research,” said Travis.

The 2015 WHO Classification of Lung Tumors captures a decade of remarkable advances in all lung cancer specialties including: pathology (histology, cytology, immunohistochemistry, molecular testing), clinical, epidemiology, radiology and genetics. The rapid expansion of molecular and immunohistochemical tools have provided a strong foundation for the classification and a rationale for reclassification of specific entities.

As a result, the role of the pathologist in lung cancer diagnosis and management has dramatically changed. Accurate pathologic diagnosis and tissue management has become more critical.

Historically, the main question asked of pathologists was to distinguish between small cell carcinoma and non-small cell carcinoma. This limited the role of pathologists in the management of lung cancer patients. However, with therapeutic and genetic advances (particularly regarding targeted therapies in patients with driver mutations in EGFR, ALK, ROS1, BRAF and RET) where treatment strategies are highly dependent on histology and genetics, pathologists now have to make more precise diagnoses and preserve tissue for molecular testing.

Since two thirds of lung cancer patients present in advanced stages, this is the most important group of tumors to address. Because these patients are not good surgical candidates, they are diagnosed based on small biopsies and cytology specimens. However, previous WHO classifications did not focus on diagnosis in small biopsies and cytology, so this is a completely new aspect to this WHO Classification and probably the most important. The urgent need for this is driven by therapeutic and genetic advances that make accurate histologic classification as well as genetic testing essential for patient management.

Critical aspects of this include:
1. New diagnostic criteria and terminology for lung cancer in small biopsies and cytology;
2. More accurate histologic subtyping;
3. Strategic management of small tissues;
4. Streamlining workflow for molecular testing;
5. Local multidisciplinary strategy for obtaining, processing and reporting these specimens.

„Most major advances in our understanding of the pathology of surgical resection specimens have occurred in lung adenocarcinoma. For resected lung adenocarcinomas, the introduction of comprehensive histologic subtyping and classification according to predominant subtype has provided a powerful tool that has led to multiple new discoveries,” Travis said.

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WHO Classifications represent a pathologic and genetic classification and grading of human tumors designed to be accepted and used worldwide; © panthermedia.net/Dimitris Kolyris
WHO Classifications represent a pathologic and genetic classification and grading of human tumors designed to be accepted and used worldwide; © panthermedia.net/Dimitris Kolyris

; Source: International Association for the Study of Lung Cancer

Drug for fungal infections in lung transplant recipients increases risk for cancer

A prescription drug commonly used to treat fungal infections in lung transplant recipients, significantly increases the risk for skin cancer and even death, according to a new study by UC San Francisco researchers. The team recommends physicians consider patient-specific factors that could modify the drug’s risks and benefits, when providing care.

„It is important for physicians to be aware of the impact of voriconazole on these outcomes,” said senior author Dr. Sarah Arron, associate professor of dermatology and director of the UCSF High Risk Skin Cancer Clinic. „We recommend that all providers counsel lung transplant recipients on skin cancer risk and photoprotection in addition to scheduling routine skin cancer screening with a trained dermatologist after transplantation. Lung transplant programs should also consider patient-specific risk factors when deciding on the type, dose and duration of antifungal prophylaxis regimens.”

Skin cancer is the most common malignancy following solid organ transplants, primarily due to immunosuppression, with recipients experiencing a greater than 65-fold increased risk of developing cutaneous squamous cell carcinoma (SCC) compared to the general population. These carcinomas are aggressive and can lead to numerous lesions, resulting in multiple debilitating surgeries and increased risk of death.

Lung transplant recipients are particularly susceptible to SCC due to older age at transplant and more intensive immunosuppression. They also have high rates of fungal infections after transplant, which can result in significant morbidity and mortality.

First approved in 2002, the medication is used to prevent and treat invasive fungal infections like those caused by the Aspergillus fungi, especially in patients with compromised immune systems such as following a lung or other organ transplant. The Aspergillus fungi can cause aspergillosis, a variety of diseases often occurring in people with healthy immune systems but having an underlying illness such as tuberculosis or chronic obstructive pulmonary disease (COPD).

However, SCC is a serious side effect, which has no clear guidelines for prophylaxis regimens despite its widespread use.

In their study, Arron and her colleagues evaluated all UCSF single-lung, double-lung or heart-lung transplant recipients receiving a transplant between October 1991 and December 2012. These 455 individuals were analyzed for voriconazole exposure and its impact on SCC, Aspergillus colonization, invasive aspergillosis and all-cause mortality.

The researchers found that voriconazole exposure resulted in a 73 percent greater risk for SCC, with each additional 30-day exposure increasing the risk by 3 percent.

Further, the drug significantly reduced the risk of Aspergillus colonization, especially in the first year after transplant, but not aspergillosis. It also reduced all-cause mortality among those transplant recipients who developed Aspergillus colonization but had no significant impact on those without colonization.

„Among lung transplant recipients with risk factors for SCC, including those with older age, male sex and white race or those in whom prolonged voriconazole administration may not have clear benefit, transplant physicians should consider limiting exposure to high doses of voriconazole or using alternative pharmacologic options that do not pose an increased risk for SCC,” said lead author Matthew Mansh, MD, who did the work as a doctoral student at Stanford University that included a research year in the UCSF Department of Dermatology.

MEDICA-tradefair.com; Source: University of California – San Francisco

UCSF researchers recommend physicians consider patient-specific factors when using voriconazole; © panthermedia.net/ invictus99
UCSF researchers recommend physicians consider patient-specific factors when using voriconazole; © panthermedia.net/ invictus99

Medical device concept: reducing time to diagnose infections

A new diagnostic device created by a collaborative team of University of Arizona engineers and scientists may significantly reduce the amount of time necessary to diagnose tissue infections.

When a patient arrives at a hospital with a serious infection, doctors have precious few minutes to make an accurate diagnosis and prescribe treatment accordingly. Doctors’ ability to act quickly and correctly not only makes a difference to the patient’s outcome, it determines whether the infection spreads to other patients in the clinic, and can even contribute to the development of drug-resistant bacteria.

Luckily for patients and doctors alike, a new diagnostic device created by collaborative team of UA engineers and scientists may significantly reduce the amount of time necessary to diagnose tissue infections. The device’s novel approach to molecular diagnostics, called DOTS qPCR, is faster, more efficient and less expensive than alternatives currently being used in clinics. The work is described online in the journal Science Advances.

„We have developed a completely different type of system than what exists out on the market,” said Dustin Harshman, a former graduate student in the Biomedical Engineering Graduate Interdisciplinary Program, currently a scientist at Ventana Medical Systems. „We want to see physicians get diagnostic information more rapidly and prescribe better initial therapies.”

Pathogens and infectious diseases are typically detected using a technique called polymerase chain reaction, or PCR. The method involves rapidly heating and cooling DNA molecules from a biological sample in a process called thermal cycling. This results in the amplification of the target DNA into millions, and even billions of copies. Scientists and physicians can then use the copies to identify the type of pathogen causing the infection. The problem is that most PCR tests can take up to an hour or more, and a physician’s decision-making window is typically less than ten minutes.

„With DOTS qPCR we are able to detect amplification and identify the infection after as few as 4 thermal cycles, while other methods are working with between 18 and 30,” said Jeong-Yeol Yoon, a professor in the Department of Agricultural and Biosystems Engineering and a joint appointment in the Department of Biomedical Engineering. „We can get from sample to answer in as little as 3 minutes and 30 seconds.”

DOTS qPCR, invented by Yoon and his research group, stands for droplet-on-thermocouple silhouette real-time PCR. The technology relies on the measurement of subtle surface tension changes at the interface of a water droplet suspended in an oil medium. The water droplet, which contains the target DNA to be amplified, is moved along a heat gradient in the oil to begin the chain reaction. As more copies of the target DNA are produced, they move towards the oil-water interface, resulting in measurable changes in surface tension. Remarkably, the size of the droplet can be measured using a smartphone camera, providing a method to observe the course of the reaction in real time.

„What’s interesting about the way we approached this is that we’ve developed a deep understanding of what’s happening at a molecular level in our system,” said Harshman, who initially struggled to determine how to monitor the course of the reaction. „That kind of understanding gave us the ability to figure out why it was failing, and then leverage that failure as an advantage to create a completely new method.”

In addition to much faster diagnosis times, the system does not require samples to be completely free of other contaminants. This can save valuable time otherwise spent preparing samples for testing.

„The system still works with relatively dirty samples,” said Yoon. „We can use very minimal processing and still make the detection in a short time.”
Yoon emphasized that DOTS qPCR is inexpensive compared to its counterparts, which employ costly and time-intensive testing methods involving fluorescence detection, lasers and dark chambers.

„It’s easy to use, smartphone-integrated and saves money and labor using expensive equipment,” explained Yoon. „This technology has a lot of commercial potential, and we’d be happy to work with industry to bring it to market.”

DOTS qPCR also has major applications in biological research, where PCR is an indispensable tool used in studying everything from hereditary disease to the evolutionary tree. Ultimately, Harshman and Yoon hope the technology will transform the operations of hospital emergency rooms, where saving time to diagnosis translates into saving lives.

„We’re envisioning a device that will provide physicians with answers as soon as they perform a biopsy, while they’re still sitting with the patient,” said Harshman. „By saving diagnosis time, we can decrease complications for patients, isolate infections to prevent spreading, and avoid creating selective pressure for antibiotic-resistant bacteria, which is a huge burden on the medical system.”

MEDICA-tradefair.com; Source: University of Arizona

A new diagnostic device created by a collaborative team of UA engineers and scientists may significantly reduce the amount of time necessary to diagnose tissue infections; © Jeong-Yeol Yoon
A new diagnostic device created by a collaborative team of UA engineers and scientists may significantly reduce the amount of time necessary to diagnose tissue infections; © Jeong-Yeol Yoon

Interview with Jan Smeddinck, Workgroup Digital Media, Center for Computing and Communication Technologies, TZI, University of Bremen

Personalized approaches in medicine are very popular. Treatment with customized therapies is intended to achieve better results and be less stressful on the patients. This could soon also be the case for physiotherapy and rehabilitation since every person is not just different – he also moves differently.

MEDICA.de spoke with Jan Smeddinck about playful exercise programs that are meant to adapt to the user, and the important role a sensor mat plays with back exercises. Also, find out how older users can be addressed with digital games.

Mr. Smeddinck, you are involved in the „Adaptify” project. What does the name stand for?

Jan Smeddinck: The name is derived from the English verb „to adapt”, which means to conform and adjust to something. This is an important point for us in playful exercise programs that support physiotherapy, rehabilitation, and prevention. They are designed to adapt to a user’s individual skills and needs.

The project’s objective is to personalize the programs for these applications. We are currently addressing problems of the lower back. Ultimately, the goal is for persons with chronic back pain to perform a greater variety of exercises than otherwise possible.

What does it look like when a program adapts to a user?

Smeddinck: Of course, mobility is different with every person, especially in therapeutic application. Needless to say, we are not able to utilize difficulty levels such as „easy – medium – hard” as we know them from commercial games; we want to be more precise. We are developing a user interface where therapists can specify how well a patient is actually still able to move and the performance goals that should be achieved after a few months.
However, automated methods are also meant to project the user’s development and present individual training plans. In this case, heuristic techniques collaborate with developmental trajectories known from medicine and individually collected user-related data that is evaluated using machine learning methods. This partial automation can subsequently support therapists in their work.

Does data protection also play a role in these types of programs?

Smeddinck: Absolutely. We want to gather mobility data from many users and different user groups. Medical data is also being incurred in a therapeutic context. This is why it is very important to properly educate users about what happens here and for us to limit ourselves to a minimum in terms of data analysis. A legal institute is a member of our project consortium to address data protection issues from the start.

The system includes two hardware components, a sensor mat, and a camera system. How are they integrated and what do they record?

Smeddinck: With modern tracking methods such as the one best known from Microsoft Kinect, an infrared camera generates a depth image of the room. It identifies a human being in it and is essentially able to offer a good assessment about the position and posture of a person’s body in space.

With a certain number of exercises, you can already identify whether the user moves correctly. However, back exercises are often done near ground level, for instance in a quadruped position, that is on your hands and knees, or lying down. In this case, it is very difficult for cameras to determine the exact body posture. That is how we came up with the idea of fusing the camera image with the input from a sensor mat. This is a type of yoga or exercise mat with embedded pressure sensors that subsequently shows how the user stands or lies down. This allows us to find out more about the skeleton’ posture and the balance distribution in the body.

What feedback about their progress can users receive from the program?

Smeddinck: There are three types of feedback. First, you get a direct visual feedback during the game, of course. Then there is feedback about the quality of the performed exercises. The user is meant to see whether he is doing the exercise correctly, is in a tilted position and compromises his balance or has turned his back in a bad position. Thirdly, the programs are also meant to record the user’s performance over time and thus determine basic parameters such as the level of physical mobility. In doing so, we can obtain a very different, objective image of the treatment process and developmental trajectories and show the user medium- and long-term trends.

All of this is reminiscent of the classic computer and video games. Can you also reach older people who are supposed to perform these types of exercises?

Smeddinck: Older people also like games, of course. There are the classic card, board or puzzle games on the one hand. On the other hand, they can also get excited about digital games. At least, this is what tests revealed with prototypes from older projects that we conducted with groups of seniors that meet in the afternoons. After a while, the majority of the group has a positive attitude about it.

Of course, we also need to reach out to the target audience. When we are older, our perception system changes, for instance, which is why our games have clearly visible graphics and line-doubled audio and visual output. Overall, they aim at a significantly lower pace, deliberately allow for breaks during the game and are better scalable in terms of difficulty.

The project will run until 2018. Can you outline its further course?

Smeddinck: Right now, we are at a point where we produce early prototypes. Over the next few months, we will start to work with users and request feedback. We subsequently want to develop programs for various user scenarios in multiple iterations; in part, to use in practices and in part, for use at home. This is actually a large stumbling block you need to remove early on: even though we need great playful mobility programs, they also need to make sense when integrating them into the complex user scenario of different target groups. At the same time, we are also refining the sensory components for the mat and work on fusing the camera image and sensor data. In about one year, we are going to move into open, practical testing and try to prepare two to three studies.

The interview was conducted by Timo Roth and translated from German by Elena O’Meara.
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JanSmeddinck

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