Integration von Therapieplanung und standardisierter Dokumentation – Ergebnisse aus der Entwicklung und Einführung eines rechnerbasierten Anwendungssystems der Pädiatrischen Onkologie

Die Pädiatrische Onkologie und Hämatologie ist gekennzeichnet durch eine relativ niedrige Inzidenzrate und einer damit verbundenen niedrigen Fallzahl der verschiedenartigen onkologischen und hämatologischen Krankheiten. Hieraus resultiert, dass in einer einzelnen Klinik nur wenig Erfahrungswissen bei Diagnostik und Therapie einer bestimmten Krankheit vorliegen kann. An der Behandlung eines Patienten in der Pädiatrischen Onkologie sind zudem relativ viele Personen, Personengruppen und Einrichtungen wie Referenzzentren beteiligt, die – als multiprofessionelles Behandlungsteam - untereinander im Sinne einer ganzheitlichen Therapie kommunizieren müssen. Trotz der niedrigen Fallzahl ist Krebs die zweithäufigste Todesursache im Kindesalter . Bei Krebserkrankungen im Kindesalter werden heutzutage in Deutschland dennoch recht gute Heilungschancen erreicht. Einen entscheidenden Beitrag hierzu haben seit den 70er Jahren multizentrische Therapieoptimierungsstudien geleistet. In den von den Studienzentralen dieser Therapieoptimierungsstudien herausgegebenen Therapieprotokollen wird eine qualitativ hochwertige und dem aktuellen Stand der Wissenschaft entsprechende Therapie definiert. Schwerpunkt dieser Behandlung ist in den meisten Fällen die Chemotherapie. Die Chemotherapieplanung für Kinder gestaltet sich äußerst komplex und aufwändig. Aufgrund der hohen Toxizität dieser Therapien kann ein Fehler in einem Therapieablaufplan zu schweren Akuttoxizitäten und Langzeitfolgen führen, weshalb Fehler unbedingt zu vermeiden sind. Darüber hinaus erfordert die Kooperation der Kliniken mit den Studienzentralen einen sehr hohen Dokumentationsaufwand. Um die benötigten Daten zur Verfügung zu stellen, ist in den Kliniken ein hoher Aufwand zu betreiben, der durch uneinheitliche Dokumentation erschwert wird. Zur Unterstützung dieser multizentrischen Umgebung war es Ziel, (i) ein Dokumentations- und Chemotherapieplanungssystem für die Pädiatrische Onkologie (DOSPO-Kernsystem) zu entwickeln, einzuführen und zu pflegen, (ii) einen Terminologieserver für die Pädiatrische Onkologie zu entwickeln und (iii) ein generisches Werkzeug (Modulgenerator) zur Erstellung von Studiendatenbanken und studienspezifischen Modulen für das DOSPO-Kernsystem auf Basis der Terminologie des Terminologieservers zu entwickeln. In dem DOSPO-Kernsystem wurde hierzu der Basisdatensatz der Pädiatrischen Onkologie umgesetzt. Neben der Dokumentation dieser Daten werden Funktionen zur Chemotherapie-Planung, Berichtschreibung, etc. bereit gestellt. Für die Dokumentation studienspezifischer Daten können studienspezifische Module entwickelt werden, die in das DOSPO-Kernsystem integriert werden. Um die Studienzentralen bei dieser Aufgabe zu unterstützen wird ein generisches Werkzeug erarbeitet. Dieses Werkzeug basiert auf dem Terminologieserver, in dem alle Merkmale der Therapiestudien der Pädiatrischen Onkologie in Deutschland standardisiert abzulegen sind. Ziel dieses Berichts ist es, einen Überblick über die Ergebnisse aus Entwicklung und Einführung des Anwendungssystems DOSPO im Hinblick auf die Integration von Therapieplanung und standardisierter Dokumentation zu geben

Impact Melt Rocks from the Late Paleocene Hiawatha Impact Structure, Northwest Greenland

Impact melt rocks formed during hypervelocity impact events are ideal for studying impact structures. Here, we describe impact melt rock samples collected proximal to the 31 km wide 58 Ma Hiawatha impact structure, northwest Greenland, which is completely covered by the Greenland Ice Sheet. The melt rocks contain diagnostic shock indicators (e.g., planar deformation features [PDF] in quartz and shocked zircon) and form three groups based on melt textures and chemistry: (i) hypocrystalline, (ii) glassy, and (iii) carbonate-based melt rocks. The exposed foreland directly in front of the structure consists of metasedimentary successions and igneous plutons; however, the carbonate-based impactites indicate a mixed target sequence with a significant carbonate-rich component. Well-preserved organic material in some melt rocks indicates that North Greenland at the time of impact was host to abundant organic material, likely a dense high-latitude temperate forest. Geochemical signatures of platinum-group elements in selected samples indicate an extraterrestrial component and support previous identification of a highly fractionated iron impactor in glaciofluvial sand. Our results illustrate the possibility to study impact structures hidden beneath a thick ice sheet based on transported samples and this opens a new avenue for identifying other potential impact craters in Greenland and Antarctica

Impact melt rocks from the Late Paleocene Hiawatha impact structure, northwest Greenland

Impact melt rocks formed during hypervelocity impact events are ideal for studying impact structures. Here, we describe impact melt rock samples collected proximal to the 31 km wide 58 Ma Hiawatha impact structure, northwest Greenland, which is completely covered by the Greenland Ice Sheet. The melt rocks contain diagnostic shock indicators (e.g., planar deformation features [PDF] in quartz and shocked zircon) and form three groups based on melt textures and chemistry: (i) hypocrystalline, (ii) glassy, and (iii) carbonate-based melt rocks. The exposed foreland directly in front of the structure consists of metasedimentary successions and igneous plutons; however, the carbonate-based impactites indicate a mixed target sequence with a significant carbonate-rich component. Well-preserved organic material in some melt rocks indicates that North Greenland at the time of impact was host to abundant organic material, likely a dense high-latitude temperate forest. Geochemical signatures of platinum-group elements in selected samples indicate an extraterrestrial component and support previous identification of a highly fractionated iron impactor in glaciofluvial sand. Our results illustrate the possibility to study impact structures hidden beneath a thick ice sheet based on transported samples and this opens a new avenue for identifying other potential impact craters in Greenland and Antarctica

Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort

Objectives:We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged-infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies.Methods: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries.Results: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT(> MIC) (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving beta-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P=0.012]. Additionally, in patients with a SOFA score of >= 9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P=0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P=0.025].Conclusions: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infections

Requirements engineering in health care : the example of chemotherapy-planning in paediatric oncology

Health care is characterized by highly complex processes of patient care that require unusual amount of communication between different health care professionals of different institutions. Sub-optimal processes can significantly impact on the patient’s health, increase the consumption of services and resources and in severe cases can lead to the patient death. For these reasons, requirements engineering for the development of information technology in health care is a complex process as well: without constant and rigorous evaluation, the impact of new systems on the quality of care is unknown and it is possible that badly designed systems significantly harm patients. To overcome these limitations, we present and discuss an approach to requirements engineering that we applied for the development of applications for chemotherapy planning in paediatriconcology. Chemotherapy planning in paediatric oncology is complex and time-consuming and errors must be avoided by all means. In the multi-hospital/multi-trial centre environment of paediatric oncology, it is especially difficult and time-consuming to analyse requirements. Our approach combines a grounded theory approach with evolutionary prototyping based on the constant development and refinement of a generic domain model, in this case a domain model for chemotherapy planning in paediatric oncology. The prototypes were introduced in medical centres and final results show that the developed generic domain model is adequate

Summary

This article is not an exact copy of the original published article in Methods of Information in Medicine. The definitive publisher-authenticated version o

Systematic planning of patient records for cooperative care and multicenter research

Purpose: The purpose of this paper is to introduce a method for systematically planning patient records for structured data entry that can be used in cooperative environments (e.g. cooperative care, multicenter trials) in a way that enables multipurpose use and shared data entry. Methods: Design research, formal logic. Results: The method suggests five steps: analyze the prevailing documentation infrastructure,provide terminology management system (TMS), provide documentation management system (DMS), plan the logical architecture, provide all necessary tools. Conclusions: The era of eHealth enables cooperative care and collaborative documentation.This can only be efficient if a multiple use and shared entry of data is realized. The task of the medical informatics community is to plan these environments systematically especiallyin complex environments which are enabled by emerging technologies

Preparing the electronic patient record for collaborative environments and ehealth

In the era of eHealth the electronic patient record is increasingly regarded as part of a collaborative environment. To efficiently support the documentary tasks and analyses a cooperative documentation infrastructure which allows multiple use and shared entry of data is necessary. The objective of this paper is to introduce a method for systematically planning such a cooperative documentation environment. It consists of the steps: analyse the prevailing documentation infrastructure, provide terminology, provide documentation management, plan the logical architecture and provide all necessary tools. The steps can be formally specified so that parameters can be automatically controlled and the environment can be updated more easily

Nursing constraint models for electronic health records : a vision for domain knowledge governance

Various forms of electronic health records (EHRs) are currently being introduced in several countries. Nurses are primary stakeholders and need to ensure that their information and knowledge needs are being met by such systems information sharing between health care providers to enable them to improve the quality and efficiency of health care service delivery for all subjects of care. The latest international EHR standards have adopted the openEHR approach of two-level modelling. The first level is a stable information model determining structure, while the second level consists of constraint models or ‘archetypes’ that reflect the specifications or clinician rules for how clinical information needs to be represented to enable unambiguous data sharing. The current state of play in terms of international health informatics standards development activities is providing the nursing profession with a unique opportunity and challenge. Much work has been undertaken internationally in the area of nursing terminologies and evidence-based practice. This paper argues that to make the most of these emerging technologies and EHRs we must now concentrate on developing a process to identify, document, implement, manage and govern our nursing domain knowledge as well as contribute to the development of relevant international standards. It is argued that one comprehensive nursing terminology, such as the ICNP or SNOMED CT is simply too complex and too difficult to maintain. As the openEHR archetype approach does not rely heavily on big standardised terminologies, it offers more flexibility during standardisation of clinical concepts and it ensures open, future-proof electronic health records. We conclude that it is highly desirable for the nursing profession to adopt this openEHR approach as a means of documenting and governing the nursing profession’s domain knowledge. It is essential for the nursing profession to develop its domain knowledge constraint models (archetypes) collaboratively in an international context