Long-term experience with setup and implementation of an IHE-based image management and distribution system in intersectoral clinical routine

Purpose

Sharing of medical data is crucial for the proper treatment of patients as it could reduce the risk of duplicated medical tests and speed up the care process if all documents are readily available. Despite great technical progress, sharing patient data while maintaining full control over the process in an intersectoral (in Germany, this describes the different actors in the healthcare system consisting of clinic, ambulatory care, etc.) setting remains a particular challenge. This paper focuses on the successful implementation of a privacy compliant, standards-based image-management component of a personal electronic health record.

Methods

Over a 5-year period, a sharing system based on readily available IHE profiles constructed around XDS has been built. It was necessary to create interfaces for the existing hospital sub-systems to become part of the network. Specifically, the imaging workflow had to be adapted to allow for fast and easy access to DICOM images utilizing a flexible web-based image viewer. In addition to the standard XDS workflow, an Imaging Cache was established which combines the Imaging Document Source and Consumer to guarantee fast and streaming-based access to all images in the network observing the high security standards of the hospital network.

Results

The authors of this paper have proven that it is possible to build a fast and reliable sharing system based on IHE profiles using most of the transactions of XDS-I with some adaptions to the clinical workflow. Primary hospital systems were enabled by building adapters to overcome lack of IHE compatibility. The established system embraces the existing security mechanisms in hospital networks while connecting patients and referring physicians from outside in a secure and convenient manner.

Conclusions

A state-of-the-art sharing system that is used in a productive clinical environment has been established and is ready to grow with more partners. The system is the basis for an elaborated interdisciplinary collaboration where data, and in particular images, can now be shared between medical professionals.

     

Near-infrared spectroscopy monitoring during immediate transition after birth: time to obtain cerebral tissue oxygenation

Feasibility of cerebral tissue oxygenation measurements immediately after birth has been published starting with first values 2 min after birth. Aim of this study was to evaluate, the time periods from birth and from arrival at the resuscitation table to obtain the first cerebral tissue oxygenation values with two different near infrared spectroscopy (NIRS) devices. The present study is an analysis of exploratory parameters of two prospective observational studies. Cerebral tissue oxygen saturation was measured by the NIRO 200NX measuring “cerebral-tissue-oxygenation-index” (cTOI) or the INVOS5100C measuring “cerebral-regional-oxygen-saturation” (crSO₂). Four time periods (T) were defined: T1 birth to arrival at resuscitation table, T2 arrival to application of NIRS sensor, T3 application to first displayed cTOI or crSO₂ value, and T4 from arrival at resuscitation table to first displayed values. Additionally, we compared first displayed values of cTOI and crSO₂. Thirty neonates were included. Twenty-four were term and six late-preterm neonates. Fifteen neonates measured with NIRO were compared to 15 measured with INVOS. T1 was 49 (6–163) s with NIRO versus 59 (15–87) s with INVOS, T2 14 (4–20) s versus 12 (15–18) s, T3 33 (13–138) s versus 17 (6–290) s and T4 46 (20–153) s and 34 (14–300) s. The first displayed value tended to be higher for cTOI [54% (18–80)] compared to crSO₂ [35% (15–87)]. There were no significant differences between devices in time periods and first values displayed. Cerebral tissue oxygenation can be measured within 1 min after arriving at the resuscitation table in term and preterm neonates after birth without difference between devices.     

Pathways to Colonoscopy in the South: Seeds of Health Disparities

Objectives. We aimed to highlight sociodemographic differences in how patients access colonoscopy.Methods. We invited all eligible patients (n = 2500) from 2 academy-affiliated colonoscopy centers in Alachua County, Florida (1 free standing, 1 hospital based), to participate in a precolonoscopy survey (September 2011–October 2013); patients agreeing to participate (n = 1841, response rate = 73.6%) received a $5.00 gift card.Results. We found sociodemographic differences in referral pathway, costs, and reasons associated with obtaining the procedure. Patients with the ideal pathway (referred by their regular doctor for age-appropriate screening) were more likely to be Black (compared with other minorities), male, high income, employed, and older. Having the colonoscopy because of symptoms was associated with being female, younger, and having lower income. We found significant differences for 1 previously underestimated barrier, having a spouse to accompany the patient to the procedure.Conclusions. Patients’ facilitators and barriers to colonoscopy differed by sociodemographics in our study, which implies that interventions based on a single facilitator will not be effective for all subgroups of a population.Colorectal cancer (CRC), the second leading cause of US cancer deaths in 2013 (50 830),1 is not distributed equally. Nationally, it is estimated that incidence is 25% higher, and mortality from CRC 50% higher, in Black Americans than in Whites.2,3 Most CRC diagnoses follow evaluation by colonoscopy. Although consumers have a range of CRC screening tests, from least invasive (fecal occult blood test, fecal immunochemical test) to most invasive (sigmoidoscopy, colonoscopy),4 if polyps are indicated, a colonoscopy is required as follow-up. Thus, colonoscopy is both an entry point and a pivotal event in the process of preventing, detecting, and treating CRC. CRC can be prevented through the removal of precancerous polyps or detected at an early, easily treatable stage5; findings indicate6 that colonoscopy with polypectomy reduces mortality from CRC by 53%. Although rates of CRC screening have increased,3 there is need for improvement. More than one third of Americans are not in compliance with screening guidelines,7 with rates being lower in the southern United States.8In 2008, Etzioni et al.9 presented a model of patient and provider-level factors that influence decision-making in colon cancer and that can lead to health disparities in disease recurrence and survival. The Etzioni model identifies key points of vulnerability in the treatment process where the potential to achieve high-quality, guideline-recommended care can be lost. The model captures patients after surgery, beginning with the decision to refer patients to a medical oncologist for adjuvant treatment; it is relevant because there is considerable evidence of inequities in who receives adjuvant treatment based on older age,10,11 comorbidities,12,13 low income,7 coverage with Medicaid rather than Medicare,13 Black race,14 female gender,15,16 and being unmarried.9We propose that this model starts too late in the process; health disparities originate prior to colonoscopy and can increase at each decision point along a continuum. In an elaborated model (Figure 1), we suggest that CRC health disparities research should begin with an investigation of entry into the health care system and the subsequent pathways to colonoscopy. Referral patterns, costs, and patient demographics influence patient access to care, colonoscopy compliance, and postcolonoscopy decision-making.Open in a separate windowFIGURE 1—Pathways to colonoscopy, treatment, and outcomes.     

Musculoskeletal ultrasound imaging training,use, and knowledge among rheumatologists in China

Clinical Rheumatology - Musculoskeletal ultrasound (MSUS) has been extensively studied by rheumatologists in Europe and the Americas, but less is known about MSUS use in Asia. Our hypothesis is...     

Mechanistic implications of altered protein expression in rheumatic heart disease

Heart Failure Reviews - Rheumatic heart disease (RHD) is a major cause of cardiovascular morbidity and mortality in low- and middle-income countries, where living conditions promote spread of group...     

New insights towards catheter-based identification of vulnerable plaque

Sudden cardiac death or unheralded acute coronary syndromes are common initial manifestations of coronary atherosclerosis and most such events occur at sites of non-flow limiting coronary atherosclerosis. Autopsy data suggests that plaque composition is a key determinant of the propensity of atherosclerotic lesions to provoke clinical events. Most of these events are related to plaque rupture and subsequent thrombotic occlusion at the site of non-flow limiting atherosclerotic lesions in epicardial coronary arteries. Detection of these non-obstructive, lipid rich, high-risk plaques may have an important impact on the prevention of acute myocardial infarction and sudden death. Currently, there are several intravascular tools capable of locally evaluating determinants of plaque vulnerability such as the size of the lipid core, thickness of the fibrous cap, inflammation within the cap and positive remodeling. These new modalities have the potential to provide insights into the pathophysiology of the natural history of coronary plaque by means of prospective studies.     

Aging and reproduction in social insects--a mini-review

Perennial social insects are characterized by the extraordinarily long lifespan of their reproductive females, which may be tens or hundreds of times larger than that of non-social insects of similar body size and also greatly surpasses that of conspecific non-reproductives. Evolutionary theories of aging explain this phenomenon from the low extrinsic mortality queens experience once they have successfully established their colony. The aim of our review is to summarize recent findings on the ultimate and proximate causes of increased queen longevity in social insects, in particular ants and honey bees. While progress is being made in elucidating the interrelations between the vitellogenin, juvenile hormone, fecundity, and senescence, we feel that the explanation for the comparatively short lifespan of queens in multi-queen societies is as yet not satisfactory and needs further attention, both concerning its proximate and ultimate basis.     

Impairment and recovery of elementary cognitive function induced by hypoglycemia in type-1 diabetic patients and healthy controls

Although neuroendocrine changes after induction of hypoglycemia, in patients with diabetes and healthy persons, are thoroughly investigated, cognitive adaptation processes are still insufficiently understood. Changes in cognitive functions are mainly investigated by psychometric tests, which represent a summation of different cognitive processes. We aimed at dissecting cognitive adaptation into single components, i.e. stimulus selection, response choice, and reaction speed during a hyperinsulinemic hypoglycemic clamp in patients with type-1 diabetes and matched healthy controls. Using novel neurophysiological analyses, the event-related potentials of early stimulus selection (selection negativity) and response selection (lateralized readiness potential) were studied, in addition to reaction time (RT). A total of 12 diabetic patients and 12 normal volunteers were studied while receiving a hyperinsulinemic hypoglycemic clamp. RTs and the event-related potentials related to stimulus selection and response selection were significantly delayed during hypoglycemia in both groups, whereas early evoked potentials (P100) were unaltered. This suggests that hypoglycemia delays stimulus selection, with the consequence that also central and motor processing are delayed. In addition, patients with diabetes showed an earlier negative shift over the frontal cortex, which, when compared with the controls, reveals better adaptation to hypoglycemia in frontal cortical brain regions. After restoration of euglycemia stimulus selection, response selection and RT returned to baseline level in the type-1 group. In the control group, however, response selection and RTs were still delayed. This suggests that type-1 patients, possibly because of the past occurrence of hypoglycemic events, might be able to better cope with the hypoglycemic state than healthy volunteers who lack such a history. In summary, our data demonstrate, for the first time, that cognitive adaptation processes to an experimental hypoglycemic episode can clearly be dissected into their single components.