Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method

Background: The extensive and rapidly expanding research literature on electronic patient records (EPRs) presents challenges to systematic reviewers. This literature is heterogeneous and at times conflicting, not least because it covers multiple research traditions with different underlying philosophical assumptions and methodological approaches. Aim: To map, interpret and critique the range of concepts, theories, methods and empirical findings on EPRs, with a particular emphasis on the implementation and use of EPR systems. Method: Using the meta-narrative method of systematic review, and applying search strategies that took us beyond the Medline-indexed literature, we identified over 500 full-text sources. We used ‘conflicting’ findings to address higher-order questions about how the EPR and its implementation were differently conceptualised and studied by different communities of researchers. Main findings: Our final synthesis included 24 previous systematic reviews and 94 additional primary studies, most of the latter from outside the biomedical literature. A number of tensions were evident, particularly in relation to: [1] the EPR (‘container’ or ‘itinerary’); [2] the EPR user (‘information-processer’ or ‘member of socio-technical network’); [3] organizational context (‘the setting within which the EPR is implemented’ or ‘the EPR-in-use’); [4] clinical work (‘decision-making’ or ‘situated practice’); [5] the process of change (‘the logic of determinism’ or ‘the logic of opposition’); [6] implementation success (‘objectively defined’ or ‘socially negotiated’); and [7] complexity and scale (‘the bigger the better’ or ‘small is beautiful’). Findings suggest that integration of EPRs will always require human work to re-contextualize knowledge for different uses; that whilst secondary work (audit, research, billing) may be made more efficient by the EPR, primary clinical work may be made less efficient; that paper, far from being technologically obsolete, currently offers greater ecological flexibility than most forms of electronic record; and that smaller systems may sometimes be more efficient and effective than larger ones. Conclusions: The tensions and paradoxes revealed in this study extend and challenge previous reviews and suggest that the evidence base for some EPR programs is more limited than is often assumed. We offer this paper as a preliminary contribution to a much-needed debate on this evidence and its implications, and suggest avenues for new research

Characterization of manganese-bearing particles in the vicinities of a manganese alloy plant

Numerous studies have associated air manganese (Mn) exposure with negative health effects, primarily neurotoxic disorders. Despite there is not a specific European regulation, institutions such as the World Health Organization (WHO) have proposed an annual average guideline value of 150 ng/m3. Bioaccessibility and toxicity mechanisms of Mn remain unclear, however it is generally agreed that adverse health effects are strongly linked to particle size and morphology, chemical composition and oxidation state. This study aims to deepen the understanding of the physico-chemical characteristics of PM10 and deposition samples collected in an urban area in the proximities of a ferromanganese alloy plant. Total Mn content was determined by ICP-MS after a microwave-assisted acid digestion. The size, morphology and chemical composition of individual particles were studied by SEM-EDX. XRD was used to identify the major crystalline phases. Most of the particles observed by SEM-EDX contain Mn. 60% of Mn-PM10 particles were spheres of small size and were attributed to condensation processes at the smelting unit. Mn-bearing particles present in deposition were characterized by irregular shapes and bigger sizes, most of them consisting of SiMn slags and Mn ores and alloys, and attributed to diffuse emissions from raw material and product handling and processing. Due to the differences in the characteristics of Mn-bearing particles found in the different matrices, further studies on the potential toxicity and health effects of these particles should be done, especially in relation with the small and spherical particles present in PM10, which are expected to be more problematic.This work has been financially supported by the Spanish Ministry of Economy and Competitiveness (MINECO) through the Project CTM2013-43904R. Ana Hernández-Pellón thanks the Ministry of Economy and Competitiveness (MINECO) for the FPI grant awarded, BES-2014-068790

Maternal selenium, copper and zinc concentrations in pregnancy associated with small-for-gestational-age infants

Pregnancy during adolescence increases the risk of adverse pregnancy outcome, especially risk of small-for gestational-age (SGA) birth, which has been linked to micronutrient deficiencies. Likewise, smoking has been shown to be related with lower micronutrient concentrations. Different ethnicities have not previously been examined. We used a subset from a prospective observational study, the About Teenage Eating (ATE) study consisting of 126 pregnant adolescents (14-18 years old) between 28-32 weeks' gestation. Micronutrient status was assessed by inductively-coupled mass spectrometry. Smoking was assessed by self-report and plasma cotinine, and SGA was defined as infants born < 10th corrected birthweight centile. The main outcome measures were: 1) Maternal plasma selenium, copper and zinc concentrations in adolescent mothers giving birth to SGA versus appropriate-for-gestational-age (AGA) infants. 2) Comparison of micronutrient concentrations between women of different ethnicities and smoking habits. The plasma selenium (mean ± SD [95% CI]) concentration was lower in the SGA (n = 19: 49.4 ± 7.3 [CI: 45.9, 52.9] μg/L) compared to the AGA (n = 107: 65.1 ± 12.5 [CI: 62.7, 67.5] μg/L; P < 0.0001) group. Smoking mothers had a lower selenium concentration compared to non-smokers (P = 0.01) and Afro-Caribbean women had higher selenium concentrations compared to White Europeans (P = 0.02). Neither copper nor zinc concentrations varied between groups, but selenium and copper were moderately correlated (P < 0.05). Selenium is an essential trace element which exerts its biological effects through the expression of a variety of important selenoproteins. Low plasma selenium concentration in adolescent mothers could contribute to the risk of delivering an SGA infant, possibly through lowering the placental antioxidant defence, thus direclty affecting fetal growth. The differences in plasma selenium between different ethnicities may relate to variation in nutritional intake, which requires further investigation

Greenhouse gas emissions from a Western Australian finfish supply chain

Greenhouse gas (GHG) emissions in the form of carbon dioxide equivalent (CO2 - eq) from two Western Australian finfish supply chains, from harvest to retail outlet, were measured using streamlined life cycle assessment methodology. The identification of interventions to potentially reduce the GHG emissions was determined from the results obtained. Electricity consumption contributed to the highest GHG emissions within the supply chains measured, followed by refrigeration gas leakage and disposal of unused fish portions. Potential cleaner production strategies (CPS) to reduce these impacts included installing solar panels, recycling the waste, good housekeeping in refrigeration equipment maintenance, and input substitution of refrigeration gas. The results show a combination of these strategies have the potential to reduce up to 35% of the total GHG emissions from fillet harvest, processing and retail

Sensitivity and specificity of NT-proBNP to detect heart failure at post mortem examination

NT-proBNP, a marker of cardiac failure, has been shown to be stable in post mortem samples. The aim of this study was to assess the accuracy of NT-proBNP to detect heart failure in the forensic setting. One hundred sixty-eight consecutive autopsies were included in the study. NT-proBNP blood concentrations were measured using a chemiluminescent immunoassay kit. Cardiac failure was assessed by three independent forensic experts using macro- and microscopic findings complemented by information about the circumstances of body discovery and the known medical story. Area under the receiving operator curve was of 65.4% (CI 95%, from 57.1 to 73.7). Using a standard cut-off value of >220 pg/mL for NT-proBNP blood concentration, heart failure was detected with a sensitivity of 50.7% and a specificity of 72.6%. NT-proBNP vitreous humor values were well correlated to the ones measured in blood (r2 = 0.658). Our results showed that NT-proBNP can corroborate the pathological findings in cases of natural death related to heart failure, thus, keeping its diagnostic properties passing from the ante mortem to the post mortem setting. Therefore, biologically inactive polypeptides like NT-proBNP seem to be stable enough to be used in forensic medicine as markers of cardiac failure, taking into account the sensitivity and specificity of the test

Magnetic resonance imaging of the knee in Norway 2002–2004 (national survey): rapid increase, older patients, large geographic differences

<p>Abstract</p> <p>Background</p> <p>Magnetic resonance imaging (MRI) of the knee is the second most common MRI examination in Norway after head/brain MRI. Little has been published internationally on trends in the use of knee MRI after 1999. This study aimed to describe levels and trends in ambulant knee MRI utilisation in Norway 2002–2004 in relation to type of radiology service, geographic regions, number of MRI-scanners, patient age and gender, and type of referring health care provider.</p> <p>Methods</p> <p>We analysed administrative data on all claims for reimbursement of ambulant knee MRI performed in Norway in 2002, 2003 and 2004 and noted nominal reimbursement. We also recorded the referring health care provider from clinical requests of ambulant knee MRI done consecutively during two months in 2004 at one private institute and three hospitals. Number of MRI-scanners was given by manufacturers and radiology services.</p> <p>Results</p> <p>In Norway, the rate of knee MRI claims for 2004 was 15.6 per 1000 persons. This rate was 74% higher in East than in North region (18.4 vs. 10.6), slightly higher for men than women (16.4 vs. 14.7) and highest for ages 50–59 years (29.0) and 60–69 years (21.2). Most claims (76% for 2004) came from private radiology services. In 2004, the referring health care provider was a general practitioner in 63% of claims (unspecified in 24%) and in 83.5% (394/472) of clinical requests. From 2002 to 2004, the rate of knee MRI claims increased 64%. In the age group 50 years or above the increase was 86%. Rate of MRI-scanners increased 43% to 21 scanners per million persons in 2004. Reimbursement for knee MRI claims (nominal value) increased 80% to 70 million Norwegian kroner in 2004.</p> <p>Conclusion</p> <p>Ambulant knee MRI utilisation in Norway increases rapidly especially for patients over 50, and shows large geographic differences. Evaluation of clinical outcomes of this activity is needed together with clinical guidelines for use of knee MRI.</p

Toenails as biomarker of exposure to essential trace metals: A review

Health problems associated with essential trace metals can result from both inadequate (i.e., low intake) and excessive exposures (i.e., from environmental and/or occupational source). Thus, measuring the exposure level is a real challenge for epidemiologists. Among non-invasive biomarkers that intend to measure long-term exposure to essential trace metals, the toenail is probably the biological matrix with the greatest potential. This systematic review collects the current evidence regarding the validity of toenail clippings as exposure biomarker for trace metals such as boron, cobalt, copper, iron, manganese, molybdenum, selenium, silicon, vanadium and zinc. Special attention was paid to the time-window of exposure reflected by the toenail, the intraindividual variability in exposure levels over time in this matrix, and the relationship of toenail with other biomarkers, personal characteristics and environmental sources. Our search identified 139 papers, with selenium and zinc being the most studied elements. The variability among studies suggests that toenail levels may reflect different degrees of exposure and probably correspond to exposures occurred 3–12 months before sampling (i.e., for manganese/selenium). Few studies assessed the reproducibility of results over time and, for samples obtained 1–6 years apart, the correlation coefficient were between 0.26 and 0.66. Trace metal levels in toenails did not correlate well with those in the blood and urine and showed low-moderate correlation with those in the hair and fingernails.This work was supported by FIS grants PI12/00150, PI17CIII/00034 & PI18/00287 (Instituto de Salud Carlos III, State Secretary of R + D + I and European Union (ERDF/ESF, "Investing in your future"))