Information security concepts and practices: the case of a provincial multi-specialty hospital

In recent years, major and widely accepted information security understandings and achievements confirm that the problem is complex. They clarify that technologies are fundamental tools, but management processes have even bigger relevance, as also prestigious international magazines dossier clearly explained recently. Such a magazine attention outlines the wide impact that the subject has on watchful decision makers. ISO17799 is an emerging standard in information security. In principle there are no reasons for considering it not applicable to the health care sector. In practice, because of both the just conceptual level of the standard and the peculiarities of the health care data and institutions, a lot of analysis and design work need to be invested any time a health care institution decides to deal with the subject. CEN/ENV 12924 is another emerging standard certainly more on the spot of the health care. Nevertheless, it also asks for evident further investigation. The practical case of information security design, implementation, management, and auditing inside a multi-specialty provincial Italian hospital will be described.     

Electronic patient-provider communication: will it offset office visits and telephone consultations in primary care?

BACKGROUND AND AIM: Electronic patient-provider communication promises to improve efficiency and effectiveness of clinical care. This study aims to explore whether a secure web-based messaging system is an effective way of providing patient care in general practices. METHOD: We conducted a randomised controlled trail and recruited 200 patients from the waiting area in one primary clinic in Norway. Participants were randomised to either the intervention group, which received access to a secure messaging system, or the control group receiving standard care without such access. Primary outcome measures were number of online consultations, telephone consultations and office visits in the two groups. Data were derived from patient records and collected 1 year prior to (baseline), and 1 year after the intervention. RESULTS: Forty-six percent of the patients who were given access to the messaging system (n=99) used the online communication system on at least one occasion (ranging from 1 to 17 messages per patient per year). A total of 147 electronic messages were sent to six general practitioners during a 1-year trial period. Eleven percent of the messages were to schedule an appointment. In 10% of the messages, the GP was unable to respond adequately and recommended an office visit. The reduction in office visits over time was greater for the intervention group than for the control group (P=0.034). There was however no significant difference in the number of telephone consultations between the groups during the study (P=0.258). CONCLUSION: The use of a secure electronic messaging system reduced the number of office visits at the general practice, but not phone consultations.     

Report of the symposium

Summary The past decades have seen considerable shifts of emphasis in surgical care. The recognition that pus was not laudable, was followed by a realisation that not all complications were inevitable and that prophylaxis could effectively reduce the incidence of most common problems in the post-operative period. As anaesthesia has become safer, it has been possible to embark on more intricate and prolonged procedures and for sufficient time to be available to ensure adequate intraoperative care.These two phenomena have firstly increased the complexity of management in the post-operative period, and have brought this aspect of surgical care more obviously to the limelight. However, many separate disciplines are involved in the care of the patient post-operatively, and the Symposium was organised¹ to bring the different groups together to identify the areas of recent development in the different specialities and to integrate the overall care of the individual patient.Abbreviations ARDS adult respiratory distress syndrome - DIC disseminated intravascular clotting     

ECLIPS: An extended clinical laboratory information processing system

The clinical laboratory is regarded as a component of the medical care system extending from physician to laboratory staff and back to physician. From this concept a computer-based system of laboratory information is derived, emphasizing: (1) total laboratory responsibility for the test and its request, and (2) physician-oriented output reports.     

Stage, survival and delays in lung, colorectal, prostate and ovarian cancer: comparison between diagnostic routes

BACKGROUND: Very few studies have reported cancer outcomes of patients referred through different routes, despite the prominence of current UK cancer urgent referral guidance. AIM: This study aimed to compare outcomes of cancer patients referred through the urgent referral guidance with those who were not, with respect to stage at diagnosis, survival, and delays in diagnosis. Design of study: Analysis of hospital records. SETTING: One hospital trust in England. METHOD: The records of 889 patients diagnosed in 2000-2001 with one of four types of cancer were analysed: 409 with lung cancer; 239 with colorectal cancer; 146 with prostate cancer; and 95 with ovarian cancer. Outcome measures were diagnostic stage, survival, referral and secondary care delays. RESULTS: For lung cancer, urgent referrals had more advanced TNM (tumor, node, metastasis) stage than patients diagnosed through other routes (P = 0.035) and poorer survival (P = 0.020). There was no difference in stage or survival for the other cancers. For each cancer, a higher proportion of urgent referrals was seen within 2 weeks. Secondary care delays for lung and colorectal cancer were shorter for inter-specialty referrals. CONCLUSION: For patients with lung cancer, the guidance appears to be prioritising those in the more advanced stages of disease. This was not the case for the other three cancers. Referral delays were shorter for patients urgently referred, as is the intention of the guidance. The avoidance of delays in outpatient diagnostics probably accounts for shorter secondary care delays for inter-specialty referrals.     

Delay between pregnancy confirmation and sickle cell and [corrected] thalassaemia screening: a population-based cohort study.

BACKGROUND: Antenatal sickle cell and thalassaemia screening sometimes occurs too late to allow couples a choice regarding termination of affected fetuses. The target gestational age for offering the test in the UK is 10 weeks. AIM: To describe the proportion of women screened before 70 days' (10 weeks') gestation and the delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening. DESIGN OF STUDY: Cohort study of reported pregnancies. SETTING: Twenty-five general practices in two UK inner-city primary care trusts offering universal screening. METHOD: Anonymised data on all pregnancies reported to participating general practices was collected for a minimum of 6 months. RESULTS: There were 1441 eligible women intending to proceed with their pregnancies, whose carrier status was not known. The median (interquartile range [IQR]) gestational age at pregnancy confirmation was 7.6 weeks (6.0-10.7 weeks) and 74% presented before 10 weeks. The median gestational age at screening was 15.3 weeks (IQR = 12.6-18.0 weeks), with only 4.4% being screened before 10 weeks. The median delay between pregnancy confirmation and screening was 6.9 weeks (4.7-9.3 weeks) After allowing for practice level variation, there was no association between delay times and maternal age, parity, and ethnic group. CONCLUSION: About 74% of women consulted for pregnancy before 10 weeks' gestation but fewer than 5% of women were screened before the target time of 10 weeks. Reducing the considerable delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening requires methods of organising and delivering antenatal care that facilitate earlier screening to be developed and evaluated.     

Environmental conditions and variation in levels of sun exposure among children in child care

Sun exposure in childhood is 1 of the risk factors for developing skin cancer, yet little is known about levels of exposure at this age. This is particularly important in countries with high levels of ultraviolet radiation (UVR) such as Australia. Among 49 children 3 to 5 years of age attending child care centers, UVR exposure was studied under 4 conditions in a repeated measures design; sunny days, cloudy days, teacher’s instruction to stay in the shade, and a health professionals instruction to apply sunscreen. Three different data collection methods were employed: (a) completion of questionnaire or diary by parents and researcher, (b) polysulphone dosimeter readings, and (c) observational audits (video recording). Results of this study indicated that more than half the children had been sunburnt (pink or red) and more than a third had experienced painful sunburn (sore or tender) in the last summer. Most wore short sleeve shirts, short skirts or shorts and cap, that do not provide optimal levels of skin protection. However, sunscreen was applied to all exposed parts before the children went out to the playground. Over the period of 1 hr (9–10 a.m.) the average amount of time children spent in full sun was 22 min. On sunny days there was more variation across children in the amount of sun exposure received. While the potential amount of UVR exposure for young children during the hour they were outside on a sunny day was 1.45 MED (Minimum Erythemal Dose), they received on average 0.35 MED, which is an insufficient amount to result in an erythemal response on fair skin even without the use of sunscreen.     

Prolactin levels in paternal striped mouse (Rhabdomys pumilio) fathers

Paternal behavior is associated with an increase in prolactin levels in fish, birds and mammals, including rodents. The striped mouse (Rhabdomys pumilio) from southern Africa shows highly developed paternal care. We investigated whether striped mouse fathers have higher prolactin levels than nonfathers, and whether there is a relationship between tactile stimulation with pups and prolactin secretion in fathers. We measured serum prolactin in 42 male striped mice assigned to one of four different experimental groups (single males, paired males, fathers housed with mother and pups, and fathers separated from their family by a wire-mesh partition). Our results revealed no increases in prolactin levels in fathers, and fathers with tactile contact with pups did not have higher prolactin levels than the fathers that were prevented from making tactile contact with pups. In contrast, experienced males had higher prolactin levels than inexperienced males. Male striped mice are polygynous in nature, living in groups, with three breeding females, and are permanently associated with pups during the breeding season. In a field study, males had higher prolactin levels during the breeding season than during the nonbreeding season. Thus, prolactin secretion in the polygynous striped mouse might be regulated by environmental stimuli, whereas social stimuli might be important for monogamous species. This is the first study to demonstrate seasonal changes in prolactin levels in a free-living male mammal.     

Importance of luxury flow for critically ill patients receiving a left ventricular assist system

The presence of a significant organ dysfunction does not immediately exclude patients from consideration for treatment with a left ventricular assist system (LVAS). However, in treating morbid circulatory shock patients with multiple organ failure, it is important to know the preoperative and postoperative factor or factors related to the recovery of the damaged organ function. In this study, we retrospectively analyzed patients receiving a LVAS at our institution and tried to determine the important factors related to the survival of patients with multisystem failure. Twenty-seven patients who underwent LVAS placement at Saitama Medical School Hospital between 1993 and 2003 were included in this study. The preoperative risk factors analyzed were renal dysfunction, respiratory dysfunction, hepatic dysfunction, the existence of active infection, and the combination of all four factors. As a postoperative factor, the pump flow index (mean LVAS pump flow during the first 2 weeks after LVAS surgery divided by the body surface area) was analyzed. None of the analyzed preoperative factors could predict survival after LVAS surgery, but a pump flow index of less than 2.5 l/min/m² had a significant relationship with death after LVAS surgery. Further analysis revealed that all the patients with a pump flow index of 3.0 l/min/m² or more could overcome preoperative organ dysfunction. Congestive heart failure patients with multisystem failure need luxury pump flow for successful LVAS surgery; this factor could be especially important in device selection and postoperative management.     

Epidemiology of adverse drug reactions in intensive care units. A multicentre prospective survey

Summary Clinically relevant events possibly attributable to drug exposure have been monitored prospectively over a period of six months in 27 general intensive care units. Fifty-four events attributed to drugs were reported in 51 patients during their stay in hospital, corresponding to an overall incidence of 1.35%. The behaviour of the physicians following attribution of the events to a prescribed drug is analyzed and discussed in detail with respect to its relationship to the quality and severity of the reaction, and the classes of drugs. Twenty-four of the 4537 monitored admissions during the six months were due to life-threatening emergencies linked to the administration of drugs (14) and radio-contrast media (10) (overall incidence 0.5%). While the clinical burden attributable to adverse drug reactions in Intensive Care Units appears to be relatively small, the analysis shows that there is ample room for a greater reduction in their incidence. Coordinators: Drs M. L. Farina and G. Tognoni, Istituto di Ricerche Farmacologiche Mario Negri, Milan; Dr F. Procaccio, Neurosurgical ICU, Ospedale Ca' Granda, Niguarda, Milan.Investigators: Drs G. Barusco, Rovigo; F. Bassi, Milan; L. Bianchetti, Torino; E. Carchietti, Udine; G. Chilloni, Reggio Emilia; G. Costantini, Savigliano (CN); P. Ferrero, Aosta; E. Geat, Trento; F. Gorgerino, Torino; A. Lusini, Empoli (FI); G. Mantovani, Ferrara; S. Marchi, Bologna; P. Marcovigi, Forli; G. Marraro, Merate (CO); F. Merlo, Vicenza; E. Pagni, Bagno a Ripoli (FI); R. Pellegrino, Cuneo; C. Peruselli, Milan; A. Piovesano, Pordenone; R. Rinaldo, Cremona; R. Ruggerini, Piacenza; S. Sammartino, Torino; A. Sartore, Cittadella (PD); A. Scaglioli, Carpi (MO); G. Scopa, Terni; G. Zeffiro, Treviso; P. Zuccoli, Parma