Decision support in medicine: lessons from the HELP system

PURPOSE: This report describes an ongoing transition from the HELP Hospital Information System to HELP II, a replacement Health Information System built to manage clinical information captured in a variety of medical settings. The focus of the article is on the medical decision support provided by this system and studied by researchers at the University of Utah and Intermountain Health Care (IHC), a large health care organization in Utah, for many years. METHODS: Select success features of the original HELP system's decision support environment are identified and lessons learned are related. Plans for transferring these features to HELP II are discussed. RESULTS: The article focuses on four features: (1) the importance of easy access to patient data essential for decision support, (2) the commitment to continued measurement and revision of both the logic and the interventional strategy in a decision support application, (3) experience with data mining as a tool for developing decision support tools, and (4) the role of clinical reports in supporting the decision making process.     

Plates, screws, and children: their relationship in craniomaxillofacial trauma

The ideal modality for fixation of pediatric craniomaxillofacial fractures remains elusive for a number of reasons. Surgeons who manage these injuries have replaced wiring techniques with the introduction of some form of reconstructive implant. The most commonly used implants are either resorbable or semi-rigid titanium. This presentation is a synopsis of the past 30 years of the English-speaking scientific literature including plastic and reconstructive surgery, otolaryngology, head and neck surgery, oral and maxillofacial surgery, pediatric, trauma, craniofacial, materials, and biomaterials publications. While no consensus on ideal management was observed, various implant treatment options are discussed, including their indications, contraindications, considerations, and consequences after implant placement.     

Enhanced cyclosporine-itraconazole interaction with cola in lung transplant recipients

BACKGROUND: Invasive aspergillosis is a major cause of morbidity and mortality in lung transplant recipients (LTR), occurring in up to 15% of patients post-transplant. The 14% aspergillus incidence at the Cleveland Clinic Foundation prompted institution of universal prophylaxis with oral itraconazole (ICZ) in 1997. We report our experience with two protocols of ICZ administration in non-cystic fibrosis LTR and the interaction with cyclosporine (CSA). METHODS: Group 1 patients (n=12) were administered ICZ capsules in a fasting or fed state, with or without a histamine-2 (H-2) receptor antagonist or proton pump inhibitor. Group 2 patients (n=12) received the same protocol as group I, but in a fed state with a carbonated beverage (cola) to increase acidity in the stomach to enhance absorption of ICZ. The ICZ dose was 200 mg/d, given as one daily dose. A historical control group (n=10) did not receive chemoprophylaxis with ICZ. CSA daily doses, dose intervals, concentration, cost, and random ICZ levels were documented over a 4-month period of time and compared using generalized estimating equations. RESULTS: The daily CSA mg/kg/d dose decreased over time in all three groups, but no differences were found between the three groups. The CSA dosing interval over time was significantly prolonged in group 2 compared to group 1 or the control group (p< or =0.003). Over time, there was no difference in CSA concentration between all groups. There was no difference in cost over time between the three groups; however, the mean cost of CSA therapy was significantly lower in group 2 compared to the control group (p=0.025). Group 2 administered ICZ with cola had greater random blood concentrations of ICZ (p=0.019). CONCLUSIONS: ICZ capsules administered in a fed state with a cola resulted in greater random levels of ICZ, a decrease in cost/d of CSA, and a prolongation of CSA dosing interval. Although daily CSA dosage trended lower in group 2, it did not reach statistical significance. We believe these changes in CSA dosing over time reflect increased absorption of ICZ and recommend verifying ICZ absorption with an itraconazole level, especially when CSA intervals are not prolonged.     

A novel method for continuous online glucose monitoring in humans: the comparative microdialysis technique

The aim of this study was to prove the feasibility of continuous subcutaneous glucose monitoring in humans using the comparative microdialysis technique (CMT). The performance of the CMT was determined by comparing tissue glucose values with venous or capillary blood glucose values in healthy volunteers and type 1 diabetic subjects. The CMT is a microdialysis-based system for continuous online glucose monitoring in humans. This technique does not require calibration by the patient. Physiological saline with glucose (5.5 mM) is pumped in a stop-flow mode through a microdialysis probe inserted into the abdominal s.c. tissue. Tissue glucose concentration is calculated by comparing the dialysate and perfusate glucose concentrations. The time delay due to the measurement process is 9 min. We tested the CMT on six healthy volunteers and six type 1 diabetic patients for 24 h in our clinical setting. Comparisons were made to HemoCue analyzer (Angelholm, Sweden) capillary blood glucose measurements (healthy volunteers) and to venous blood glucose concentration determined with a Hitachi analyzer (diabetic patients). The mean absolute relative error of the CMT glucose values from the blood glucose values was 17.8+/-15.5% (n = 167) for the healthy volunteers and 11.0+/-10.8% (n = 425) for the diabetic patients. The mean difference was 0.42+/-1.06 mM (healthy volunteers) and -0.17+/-1.22 mM (diabetic patients). Error grid analysis for the values obtained in diabetic patients demonstrated that 99% of CMT glucose values were within clinically acceptable regions (regions A and B of the Clarke Error Grid). The study results show that the CMT is an accurate technique for continuous online glucose monitoring.     

Cystic fibrosis patients with and without central nervous system complications following lung transplantation

Central nervous system (CNS) complications occur more frequently in cystic fibrosis (CF) patients than other lung transplant recipients. The purpose of this study was to compare CF patients with and without CNS complications following lung transplantation, to identify risk factors for CNS events. Records of 21 patients with CF who underwent lung transplant between 1991-1996 were reviewed. Data were collected on multiple variables, including: age at transplant; gender; cytomegalovirus (CMV) status; cholesterol and triglyceride levels; sinusitis; percent ideal body weight (IBW); body mass index (BMI); augmented immunosuppression, acute lung rejection episodes (ALR); cyclosporine doses; electrolytes; magnesium, blood urea nitrogen (BUN), and creatinine levels; and 6-month survival. CNS complications identified were seizures, severe headaches (HA), strokes, or confusional episodes. Eleven of 21 patients (52%) with CF had CNS events: eight had seizures, five HA, three strokes, and one confusional episode. There was no difference in age at transplant, pretransplant percent IBW or BMI, cholesterol and triglyceride levels, or number of ALR. CMV mismatch and clinical sinusitis had no effect. Cyclosporine doses did not differ between groups at 30 days, or 3 or 6 months posttransplant. Both BUN and creatinine concentrations showed a rise over time that did not differ between groups. Potassium levels were within normal limits for both groups. While sodium levels did not differ between groups pretransplant, or at 30 days or 6 months posttransplant, a decrease in sodium values was seen at the time of CNS events. There was no difference in 6-month survival. We could not identify any pre- or posttransplant risk factors that predicted CNS events. It is likely that cyclosporine toxicity is the major cause of CNS complications. Despite the high rate of CNS events, the overall prognosis was good, and 6-month survival was not affected.     

SLOVENE SOCIETY

In the treatment of symptomatic endometriosis, the aim is to achieve complete surgical removal of the lesions. Primary laparotomy is often regarded as the standard surgical approach for removing intestinal endometriosis. The aim of this retrospective study was to clarify the advantages and disadvantages of combined vaginal-laparoscopic 'en-bloc' resection in comparison with primary laparotomy in patients with endometriosis spreading to the rectum. From October 2002 to June 2005, 28 patients with spreading rectovaginal endometriosis underwent surgery. Infiltration of the rectum was present in all cases. The postoperative evaluation was carried out using outpatient and in-patient medical files, histological findings, surgical reports, and follow-up of the patients for a period of up to 36 months. Anterior rectal resection due to rectal endometriosis was successfully carried out in 11 patients using a combined vaginal-laparoscopic procedure, and in nine patients via a primary laparotomy. Intra-operative conversion of the procedure from primary laparoscopy to laparotomy was necessary in eight cases due to marked adhesions or massive ureteral involvement. The hospitalization period was significantly shorter with the laparoscopic procedure than in patients undergoing laparotomy. No significant differences were found between the two methods with regard to postoperative complications, recurrence rates, establishment of an artificial anus, wound healing disturbances, or functional disturbances of the intestine or bladder. The combined vaginal-laparoscopic procedure for removing rectal endometriosis via an anterior rectal resection can be regarded as a method that is equally as effective as primary laparotomy. Further studies with longer follow-up periods are needed in order to study the long-term results, including the quality of life for the patients concerned.     

Sekundäre Rekonstruktion des digitalen A2-Ringbands

Objective

Secondary reconstruction of A2 flexor pulley for after closed rupture.

Indications

Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints.

Contraindications

Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints.

Surgical technique

A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost.

Postoperative management

Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months.

Results

Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97?%, the average power grip strength 96?%, the finger pinch strength 100?%, and the average circumference 95?% of the uninjured contralateral side. The Buck–Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.     

Second free radial forearm flap for urethral reconstruction after partial flap necrosis of tube‐in‐tube phalloplasty with radial forearm flap: A report of two cases

We present a salvage procedure to reconstruct the neo‐urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube‐in‐tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo‐urethra and a strip of the outer lining of the neo‐phallus. Neo‐urethra‐reconstruction was performed with a second RFF from the contralateral side providing well‐vascularized tissue. No flap‐related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo‐phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo‐urethra and reconstructed the outer lining of the neo‐phallus © 2013 Wiley Periodicals, Inc. Microsurgery 34:58–63, 2013.     

Beta2 integrin/ICAM-1 adhesion molecule interactions in cutaneous inflammation and tumor promotion

The beta2 integrin (CD 18/CD 11 a, b, c) family of proteins mediate adherence of leukocytes to vascular endothelium and the associated ligand, intercellular adhesion molecule-1 (ICAM-1; CD 54), interacts with beta2 integrin proteins to allow transendothelial migration of leukocytes into sites of inflammation. The present study examines the function of these proteins in a murine model of acute cutaneous inflammation induced following topical application of 12-O- tetradecanoylphorbol-13-acetate (TPA) to the dorsal epidermis of SENCAR mice and in a model of skin multistage carcinogenesis. At 24 h following topical application of TPA to the dorsal epidermis of mice, dermal leukocytes expressed higher levels of beta2 integrin protein compared with the lower levels of beta2 integrin protein expression by peripheral blood leukocytes. ICAM-1 protein was localized to epidermal keratinocytes and vascular endothelium in TPA-treated skin and to proliferating papilloma cells. Intravenous (i.v.) injection of either 50 microg anti-beta2 integrin antibody alone or in combination with anti-ICAM-1 antibody significantly inhibited both TPA-stimulated neutrophil infiltration into the dermis (P < 0.001) and myeloperoxidase (MPO) activity (P < 0.03 anti-beta2 integrin antibody; P < 0.01 anti- beta2 integrin + ICAM-1 adhesion molecule antibodies), but had no effect on TPA-induced epidermal hyperplasia. In addition, injection of either anti-ICAM-1 adhesion molecule antibody alone (P < 0.004) or in combination with anti-beta2 integrin antibody (P < 0.001) significantly inhibited TPA-induced production of 7,8-dihydroxy-2'-deoxyguanosine (8- OHdG) immunoreactive proteins by epidermal keratinocytes. Beta2 integrin/ICAM-1 adhesion molecules work in concert to regulate migration, retention and functional activation of leukocytes within the dermis during TPA-induced skin inflammation and within stromal tissue of papillomas that form during multi-stage carcinogenesis. Agents that inhibit these receptor/ligand interactions may be useful in defining the roles of specific cell populations in cutaneous inflammation and multistage carcinogenesis and may also have potential as anti-promoting and anti-progression agents.