Electronic patient record development in Norway: The case for an evolutionary strategy

With the failure of many large-scale “big-bang” projects, combined with the lack of influence associated with many small-scale projects, we need to look for alternative strategies for implementing ICT in healthcare. One such strategy is to focus on the processes that enable successful scaling of locally developed ICT systems and how these gain a foothold in a larger market. In this paper, we contribute with empirical insight into one such scaling process. We illustrate how scale is both connected to a vendor's strategy of maintaining close user contact and influenced by how the authorities choose to organize the healthcare system. Empirically, the study draws on the establishment and growth of the Norwegian company DIPS ASA over a period of nearly 25 years, which today claims the lion's share of the electronic patient records market in Norwegian hospitals.     

Dependence and perceived difficulty in activities of daily living in adults with cerebral palsy and spina bifida

Purpose : The purpose of this study was to identify differences between two groups of subjects: one with cerebral palsy, the other with spina bifida in their dependence and their perceived difficulty in performing daily activities according to the Functional Independence Measure (FIM) and the Instrumental Activity Measure (IAM), and to compare these findings with the reported use of assistance. Method : Community-living persons, 53 with cerebral palsy and 20 with spina bifida, aged 20 to 39 years, participated in semistructured interviews in their homes, where rating was performed using items from FIM and IAM. Results : Differences were found for the reported use of assistance and the dependence rated according to FIM and IAM. Significant differences for dependence were found between the CP and SB subjects concerning Eating, Bladder and Bowel items and for perceived difficulty concerning toileting, bladder and bowel. There was close overall agreement between dependence and perceived difficulty, except for the item walk/wheelchair. Conclusions : Subjects in both groups needed help in basic and instrumental ADL. The ability of spina bifida subjects was more influenced in toileting, bladder, bowel than the cerebral palsy subjects and tended also to be so in mobility instrumental tasks. FIM and IAM do not cover all aspects of significance in community-living adults. Further items have to be developed, covering personal care and occupational as well as leisure domains.     

Postoperative mental impairment in hip fracture patients: A randomized study of reorientation measures in 223 patients

Mental impairment is a common and serious complication in geriatric surgery. We studied 223 hip fracture patients. They were over 64 years of age (mean 81), with no history of mental deterioration and acutely admitted to hospital from independent living conditions. They were randomized into two groups. One of these was subjected to reorientation measures during the perioperative phase, i.e., presurgery admission to the orthopedic ward, accompanied home visits during the hospital stay and access to reorientation devices-they received a large clock, calendar, radio, TV-set, telephone and were encouraged to wear their own clothing. Otherwise, there were no differences in the treatment given to the two groups. We used monitoring of cognitive function with the Short Portable Mental Status Questionnaire (SPMSQ) and a feedback program for evaluation of the treatment results.

There was a low incidence of postoperative cognitive deterioration in both groups, compared with historical controls. However, no difference in mental status was noted when we compared the two groups. The conclusion is that attributes were less important than the psychological environment for postoperative mental deterioration. The mean total continuous hospitalization (transfers between departments and hospitals included) in the reorientation group was 22 (95% CI: 17-43) days, the corresponding figures for the controls were 30 (14-29) days.     

Salvage radiotherapy in patients with persistently detectable PSA or PSA rising from an undetectable range after radical prostatectomy gives comparable results

Purpose

Salvage radiotherapy (SRT) is applied routinely in patients with a biochemical relapse after radical prostatectomy (RP). Although the detection threshold for relapse after RP has steadily been lowered, only about 30 % of the SRT patients achieve a durable response. We have previously shown the association between a PSA decrease below detectable levels after SRT and biochemical progression-free survival (BPFS). After recalculating our data according to a more recent definition of biochemical failure after SRT, we now show the significance of the post-RP PSA nadir.

Materials and methods

Among 159 prostate cancer patients without hormonal treatment after RP, SRT was given to 72 patients with persistently detectable PSA after RP and to 87 whose PSA increased out of an undetectable range. The median pre-SRT PSA was 0.29 ng/ml for the former group and 0.34 ng/ml for the latter group. A radiation dose of 66.6 Gy was applied to the prostate bed.

Results

The overall median follow-up time was 41.7 months. The probability for BPFS after this period was 52.8 % in 72 patients with persistently detectable PSA after RP and 65.4 % in 87 patients who had a post-RP PSA nadir below detection limit. Univariate and multivariate analyses showed no significant difference in BPFS of both patient groups (p > 0.05).

Conclusion

Our findings suggest that SRT is a viable treatment option for patients with persistently detectable PSA, giving similar results as in patients whose PSA increases out of an undetectable range after RP.     

Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases.

OBJECTIVE: To investigate the computed tomography (CT) features of malignant pleural mesothelioma (MPM) cases, comparing them to those in other malignant and benign pleural diseases. MATERIALS AND METHODS: We reviewed the CT findings of 215 patients; 99 with MPM, 39 with metastatic pleural disease (MPD), and 77 with benign pleural disease. The findings were evaluated in univariate and multivariate analysis for differentiation of pleural diseases. RESULTS: In patients with MPM, the most common CT features were circumferential lung encasement by multiple nodules (28%); pleural thickening with irregular pleuropulmonary margins (26%); and pleural thickening with superimposed nodules (20%). In the majority (70%) of cases, there was rind-like extension of tumor on the pleural surfaces. In multivariate analysis, the CT findings of "rind-like pleural involvement", "mediastinal pleural involvement", and "pleural thickness more than 1 cm" were independent findings in differentiating MPM from MPD with the sensitivity/specificity values of 70/85, 85/67, and 59/82, respectively. "Rind-like pleural involvement", "mediastinal pleural involvement", "pleural nodularity" and "pleural thickness more than 1 cm" were independent findings for differentiation of malignant pleural diseases (MPM+MPD) from benign pleural disease with the sensitivity/specificity values of 54/95, 70/83, 38/96, and 47/64, respectively. Invasion of thoracic structures such as pericardium, chest wall, diaphragm, mediastinum, with pleural disease and nodular involvement of fissures, was detected infrequently; however, since these invasions were not seen in benign pleural diseases, it was concluded these invasions, if detected on a CT scan, directly suggested malignancy. CONCLUSION: A patient has extremely high probability of malignant pleural disease if one or more of these CT findings are found and the possibility of MPM is high. These findings may be important for patients in bad state or patients who do not want any invasive biopsy procedures. It is also possible to identify cases with a low probability of malignant disease.     

The Vista system: a new bipolar resection device for endourological procedures: comparison with conventional resectoscope

OBJECTIVE: Conventional transurethral resection of the prostate (TURP) uses a monopolar electrocautery system in which the current passes from the active electrode through the patient's body towards the return plate and may cause distant negative effects. In this study a new developed resection device, the Vista system, using a bipolar electrocautery system and 0.9% sodium chloride solution for irrigation, was evaluated in an ex-vivo model. METHODS: The modified model of the isolated blood perfused kidney was used to determine cutting qualities, ablation rate, blood loss and coagulation depth of the bipolar resectoscope. After ablating the renal tissue of a perfused kidney in a surface area, blood loss was semiquantitatively determined. Afterwards samples were taken and processed for histological evaluation of the coagulation depth. We compared the new bipolar resection device against a conventional monopolar resectoscope. RESULTS: We found good cutting qualities of the bipolar resectoscope although it is more difficult to start a cut. The ablation rate is determined by the width of the electrode and is similar to the standard device (30 cm(2)/min). The bleeding is reduced with increasing output powers (26.13 +/- 6.15 g/min (level 5); 20.49 +/- 5,47 g/min (level 6); 13.16 +/- 5,47 g/min (level 7); 10.43 +/- 4.76 g/min (level 8) and lower compared to a conventional monopolar resectoscope (17.08 +/- 4.47 g/min). The coagulation depth increases with higher output powers but is reduced compared to the standard device (118 +/- 22 microm (level 5); 121 +/- 23 microm (level 6); 141 +/- 62 microm (level 7); 163 +/- 30 microm (level 8) versus 287 +/- 57 (monopolar resectoscope)). CONCLUSION: Our results with the bipolar resection device for TURP suggest that it may offer an alternative to conventional TURP. As active and the return electrode are placed on the resectoscope, high current densities are achieved locally and complications caused by distant negative effects of the current are theoretically reduced in vivo. Furthermore the risk of TUR syndrome is theoretically eliminated by using physiological sodium chloride solution for irrigation. To prove the clinical significance of our ex-vivo findings, clinical studies including large numbers of patients have to be performed.     

Mid-Thigh Cortical Bone Structural Parameters,Muscle Mass and Strength,and Association with Lower Limb Fractures in Older Men and Women (AGES-Reykjavik Study)

In a cross-sectional study we investigated the relationship between muscle and bone parameters in the mid-thigh in older people using data from a single axial computed tomographic section through the mid-thigh. Additionally, we studied the association of these variables with incident low-trauma lower limb fractures. A total of 3,762 older individuals (1,838 men and 1,924 women), aged 66–96 years, participants in the AGES-Reykjavik study, were studied. The total cross-sectional muscular area and knee extensor strength declined with age similarly in both sexes. Muscle parameters correlated most strongly with cortical area and total shaft area (adjusted for age, height, and weight) but explained <10 % of variability in those bone parameters. The increment in medullary area (MA) and buckling ratio (BR) with age was almost fourfold greater in women than men. The association between MA and muscle parameters was nonsignificant. During a median follow-up of 5.3 years, 113 women and 66 men sustained incident lower limb fractures. Small muscular area, low knee extensor strength, large MA, low cortical thickness, and high BR were significantly associated with fractures in both sexes. Our results show that bone and muscle loss proceed at different rates and with different gender patterns.