Making wise decisions for completion thyroidectomies

Unilateral differentiated thyroid cancer (DTC) <4 cm can be treated with thyroid lobectomy or total thyroidectomy (TT), depending on the presence of high-risk features. Information about some of these features, such as micrometastasis in lymph nodes or microscopic extrathyroidal extension (ETE), are usually incidental findings that only become available after histological assessment from the first surgery. If such features or risk factors are present, physicians face the dilemma of suggesting completion thyroidectomy or not. There is often considerable room for clinical judgement in these cases, even though thyroid cancer guidelines generally say that completion thyroidectomy should be offered as if the information were available before the initial surgery. In this issue of Gland Surgery, Choi and coworkers (1) provide data that may help clinicians making their wise decisions when faced with this situation. The authors looked at patients whose American Thyroid Association (ATA) risk classification was upstaged from low to intermediate after incidental findings of lymph node micrometastasis or microscopic ETE. The authors present data from 2,830 patients treated for assumed low risk DTC with lobectomy and prophylactic ipsilateral central compartment neck dissection (CCND). Patients with lymph node metastasis >2 mm or gross ETE of the cancer were treated with TT and not included in the study. Thus, patient selection included only “the better part” of intermediate risk patients. The presence of micrometastasis or microscopic ETE, two features that according to ATA guidelines (2) would add to the argument for completion thyroidectomy, did not change the treatment strategy at the author’s clinic. This allowed the unique opportunity for the authors to compare long-term oncological outcomes for patients with micrometastasis in the central lymph nodes or microscopic ETE, to those who had not, without further surgical or radioiodine treatment

Severe hypercalcemia caused by parathyroid hormone in a rectal cancer metastasis: a case report

Background - Hypercalcemia of malignancy is relatively common in several cancers. However, in colorectal cancer, paraneoplastic phenomena that cause hypercalcemia is uncommon. In the few cases that are reported, secretion of parathyroid hormone-related peptide mediates the effect. We describe the first case of severe hypercalcemia mediated by intact parathyroid hormone secretion from a bone metastasis of colorectal origin. This was a diagnostic and therapeutic challenge. Case presentation - A 68-year-old male treated for rectal adenocarcinoma 10 years earlier developed a bone metastasis. After initial treatment of the metastasis with surgery and irradiation, he developed a relapse with severe hypercalcemia and corresponding elevated parathyroid hormone levels. The workup showed no signs of parathyroid adenomas, but the metastasis produced intact parathyroid hormone. The hypercalcemia was successfully treated by irradiation and osteoclast inhibitor, and the patient received chemotherapy. Survival was 24 months from the onset of hypercalcemia. Conclusions - Proper diagnosis of the uncommon endocrine disturbance allowed targeted therapy and avoidance of neck exploration for wrongly suspecting primary hyperparathyroidism. Intact parathyroid hormone should be measured in cases of malignant hypercalcemia

Patient-tailored levothyroxine dosage with pharmacokinetic/pharmacodynamic modeling: A novel approach after total thyroidectomy

Background: After seven decades of levothyroxine (LT4) replacement therapy, dosage adjustment still takes several months. We have developed a decision aid tool (DAT) that models LT4 pharmacometrics and enables patient-tailored dosage. The aim of this was to speed up dosage adjustments for patients after total thyroidectomy. Methods: The DAT computer program was developed with a group of 46 patients post-thyroidectomy, and it was then applied in a prospective randomized multicenter validation trial in 145 unselected patients admitted for total thyroidectomy for goiter, differentiated thyroid cancer, or thyrotoxicosis. The LT4 dosage was adjusted after only two weeks, with or without application of the DAT, which calculated individual free thyroxine (fT4) targets based on four repeated measurements of fT4 and thyrotropin (TSH) levels. The individual TSH target was either <0.1, 0.1–0.5, or 0.5–2.0 mIU/L, depending on the diagnosis. Initial postoperative LT4 dosage was determined according to clinical routine without using algorithms. A simplified DAT with a population-based fT4 target was used for thyrotoxic patients who often went into surgery after prolonged TSH suppression. Subsequent LT4 adjustments were carried out every six weeks until target TSH was achieved. Results: When clinicians were guided by the DAT, 40% of patients with goiter and 59% of patients with cancer satisfied the narrow TSH targets eight weeks after surgery, as compared with only 0% and 19% of the controls, respectively. The TSH was within the normal range in 80% of DAT/goiter patients eight weeks after surgery as compared with 19% of controls. The DAT shortened the average dosage adjustment period by 58 days in the goiter group and 40 days in the cancer group. For thyrotoxic patients, application of the simplified DAT did not improve the dosage adjustment. Conclusions: Application of the DAT in combination with early postoperative TSH and fT4 monitoring offers a fast approach to LT4 dosage after total thyroidectomy for patients with goiter or differentiated thyroid cancer. Estimation of individual TSH-fT4 dynamics was crucial for the model to work, as removal of this feature in the applied model for thyrotoxic patients also removed the benefit of the DAT

Architecture of a consent management suite and integration into IHE-based regional health information networks

<p>Abstract</p> <p>Background</p> <p>The University Hospital Heidelberg is implementing a Regional Health Information Network (RHIN) in the Rhine-Neckar-Region in order to establish a shared-care environment, which is based on established Health IT standards and in particular Integrating the Healthcare Enterprise (IHE). Similar to all other Electronic Health Record (EHR) and Personal Health Record (PHR) approaches the chosen Personal Electronic Health Record (PEHR) architecture relies on the patient's consent in order to share documents and medical data with other care delivery organizations, with the additional requirement that the German legislation explicitly demands a patients' opt-in and does not allow opt-out solutions. This creates two issues: firstly the current IHE consent profile does not address this approach properly and secondly none of the employed intra- and inter-institutional information systems, like almost all systems on the market, offers consent management solutions at all. Hence, the objective of our work is to develop and introduce an extensible architecture for creating, managing and querying patient consents in an IHE-based environment.</p> <p>Methods</p> <p>Based on the features offered by the IHE profile Basic Patient Privacy Consent (BPPC) and literature, the functionalities and components to meet the requirements of a centralized opt-in consent management solution compliant with German legislation have been analyzed. Two services have been developed and integrated into the Heidelberg PEHR.</p> <p>Results</p> <p>The standard-based Consent Management Suite consists of two services. The Consent Management Service is able to receive and store consent documents. It can receive queries concerning a dedicated patient consent, process it and return an answer. It represents a centralized policy enforcement point. The Consent Creator Service allows patients to create their consents electronically. Interfaces to a Master Patient Index (MPI) and a provider index allow to dynamically generate XACML-based policies which are stored in a CDA document to be transferred to the first service. Three workflows have to be considered to integrate the suite into the PEHR: recording the consent, publishing documents and viewing documents.</p> <p>Conclusions</p> <p>Our approach solves the consent issue when using IHE profiles for regional health information networks. It is highly interoperable due to the use of international standards and can hence be used in any other region to leverage consent issues and substantially promote the use of IHE for regional health information networks in general.</p

Målinger i troposfæren med ALOMAR RMR lidar: Temperaturmålinger med bruk av rotasjons Raman spektrum og bestemmelse av dens optiske overlap.

Alomar troposfæriske lidar var ikke operativ grunnet en feil med laseren og trengte en erstatter. Den fikk en ny laser under skrivingen av denne oppgaven. I denne oppgaven ble det prøvd en midlertidig løsning hvor RMR-lidaren på ALOMAR ble brukt for troposfæremålinger. RMR-lidaren er ustyrt med rotasjons-Raman kanaler som er brukt til å måle temperaturer i troposfæren. RMR-lidaren er konstruert for målinger i den øvre atmosfære og har derfor en ukomplett optisk overlap i tropsfæren. Den optiske overlapsfunksjonen for RMR teleskopene vil bli funnet på forskjellige metoder slik at RMR-lidaren kan bli brukt for andre målinger i troposfæringen. Overlapsfunksjonen er og blitt brukt til å sammenligne data fra RMR og den troposfæriske lidaren

Electronic collaboration across organizational borders in the health care sector: Design and deployment from a national perspective

The purpose of this thesis is to make a contribution to the improvement of electronic collaboration across organizational borders in the health care sector. I have studied this problem from a sociotechnical1 point of view and have tried to find out what we can learn from the process and how lessons learned could potentially influence further development and deployment of collaboration systems at a national level. I have used electronic referrals as a case. Practice consultants are General Practitioners (GPs) who work in part-time positions at the hospital, and I have paid special attention to their potential role in collaboration projects. I have also discussed the need for electronic collaboration as a basis for the coming Coordination Reform (Samhandlingsreformen). Research questions My research questions are the following: Q1 What is the status and what are the needs for electronic collaboration in the health sector in Norway? Q2 How can practice consultants influence the development and deployment of electronic referrals? Q3 How can general practitioners influence national ICT-strategy processes and national electronic collaboration projects? Q4 How can a basis for more widespread electronic collaboration, including referrals, be established from a sociotechnical perspective? Methods My work has been based on use of mixed methods, both qualitative and quantitative. I initially did a review to get an overview of large referral projects. I did a database search, and I also used national strategy documentation, action plans and project documentation as a basis for the review. To supply the review data, I conducted a national survey of the development of electronic referrals in collaboration with the Directorate of Health and their project Meldingsløftet (The Message boost project). Case studies I have done four case studies: 1. Case study of the coordination reform and the role of electronic collaboration. A situation analysis of eight trajectories that span primary and secondary care was performed. 2. Case study of the specification and development of a Core EHR. 3. Case study of the GP’s National Reference Group. 4. Case study of a hospital and six GP practices that were involved in the introduction of decision support in the referral process. Information for the case studies has been gathered by: &nbsp;Observations though my participation in the projects.&nbsp;Semistructured individual interviews and group interviews.&nbsp;Reading of project documentation as minutes from meetings, reports and plans.&nbsp;Reading of national strategy documentation. Main contributions C1.Suggestions on how practice consultants can influence the development and deployment of electronic referrals (Q2) Practice consultants should be involved in design of modules and systems that support the GP’s work processes regarding electronic referrals. They should be considered for the role of pilot users in electronic referral projects and should be used in anchoring processes and take part in processes to make agreements about the content and structure of information that should be transferred. C2. Suggestions on actions that national bodies can take to make more reliable plans for the development and deployment of ICT systems that support collaboration (Q1, Q3, Q4) National bodies need longer strategic planning periods and should plan for more stepwise implementation of ICT systems than the practice is today. The Coordination Reform is not supported by necessary electronic collaboration solutions, and more attention should be paid to improve electronic collaboration systems from a national view. National projects need to be anchored at a local level and reference groups like the GPs’ EHR reference group should be considered used. Decision support and booking are commonly used in other countries. There is a need for further development in Norway, but it was also hard to see quality improvements for the hospital from the decision support case in the thesis. C3. Suggestions on how clinicians can influence national ICT-strategy processes and national electronic collaboration projects (Q3) Experiences from national EHR reference group show that the group can be used to coordinate input from GPs to national authorities, vendors and national projects. National authorities should consider funding of the group. C4. Suggestions on how the design and deployment of electronic collaborations in the health sector can be supported from a sociotechnical viewpoint (Q4) The design and deployment of collaborative systems can benefit from the use of frameworks such as the Locales and Boundary frameworks to ensure that sociotechnical aspects are addressed. New functionality to support collaboration must be integrated into the GPs EHR systems. GPs and specialists may have a different view on, and different use of, information that is transferred (e.g., a discharge letter or referral). Common understanding and agreement are needed and the practice consultants can be used as mediators. This thesis is based on the status and needs of the health care system in a Norwegian context. The results from my work are not necessarily transferable to other countries because many factors, such as the organization of the health sector, incentive models, legislation and the installed base of information systems, differ substantially between countrie

Modellering av strømtransformatorer og verifikasjon i høystrømlab

Rapporten omhandler magnetisk metning i beskyttende strømtransformatorer. Forståelsen av metning er viktig for å øke driftssikkerheten i kraftsystemet. En Arteche CTI-420 strømtransformator ble stilt til disposisjon under oppgaven av Statnett. Denne ble testet under normal drift og under metning i høystrømlabben. Forskjellige byrder og strømstyrker ble påtrykket primærsiden for å fremprovosere metning. Responsen til strømtransformatoren ble lagret med et oscilloskop, og sammenlignet med simuleringer fra SINTEFs strømtransformatormodell i PSCAD. Det ble også utført tester for å måle magnetiseringskarakteristikk, kjernetap, kortslutningsimpedans og DC-motstanden i viklingen. Kortslutningsimpedansen viste seg å være vanskelig å måle, men en metode for å gjøre dette har blitt foreslått. Effekten av de forskjellige parameterne ble studert i strømtransformatormodellen fra SINTEF. Resultatet viser at kortslutningsimpedansen har liten betydning for responsen og kan neglisjeres. Feil i magnetiseringskarakteristikken ble påvist å være en større kilde til avvik mellom simulert respons og målt respons i høystrømlab. På grunn av de lave verdiene for fluks i testrapporten, sammenlignet med de som oppstår under en kortslutning i nettet, må modellen ekstrapolere magnetiseringskarakteristikken for å finne magnetiseringsstrømmen under en kortslutning. Denne ekstrapoleringen blir lite nøyaktig når store verdier av fluks induseres i kjernen. En modulbasert modell i PSCAD ble utviklet og sammenlignet med SINTEFs modell. Komponenten saturable reactor ble brukt for å modellere magnetiseringsstrømmen. Denne komponenten viste seg å være tungvindt i bruk, og uegnet for å representere magnetiseringskarakteristikken på en tilfredsstillende måte