Participatory design for computerization of clinical practice guidelines.

There have been made many attempts on computerization of clinical practice guidelines (CPGs), none have, however achieved any general application in clinical work practice. The objective of this paper is: (1) to raise awareness about the impact the design method used for computerization of CPGs have on the final solution and (2) to explore the potential benefits--and disadvantages--of participatory design (PD) as an approach to design. However, rather than attempting to comprehensively cover the whole field of PD pertinent to healthcare, we focus on providing details on three aspects of PD: PD as a design philosophy, PD as a toolbox and PD as a way to create a shared realm of understanding among IT-designers and health professionals as these are areas of utmost relevance for the design of computerized CPGs. Additionally, the application of PD for computerization of CPGs is illustrated by two cases. We conclude that PD is a beneficial approach for design of computerized CPGs.

Cardiovascular and respiratory changes and convalescence in laparoscopic colonic surgery: comparison between carbon dioxide pneumoperitoneum and gasless laparoscopy.

HYPOTHESIS: Gasless laparoscopy produces smaller cardiopulmonary and systemic changes than carbon dioxide (CO2) laparoscopy during colonic surgery. DESIGN: Prospective randomized trial. SETTING: Department of Surgery in a university hospital. PATIENTS: Twenty-two patients scheduled for laparoscopic colonic resection; 5 patients were excluded because of conversion to open surgery (N = 17). INTERVENTIONS: Patients were randomized to either gasless (n = 9) or conventional CO2 (n = 8) surgery. MAIN OUTCOME MEASURES: Intraoperative assessment of hemodynamic factors and pulmonary function, and postoperative assessment of pain, pulmonary function, convalescence, and various injury factors were done several times until 30 days after surgery. Surgical complications were noted. RESULTS: Descending aorta blood flow after 30 minutes (P=.03) and heart rate after 150 minutes were higher in the CO2 group (P=.009). Central venous pressure, PaCO2 inspiration pressure, and end tidal CO2 level were significantly higher in the CO2 group (P = .05, .03, .04, and .01, respectively). Patients in the CO2 group had less pain during mobilization and coughing (P = .008 and .006, respectively), and were significantly more fatigued (P = .04). No other important differences were observed in intraoperative hemodynamic factors, postoperative convalescence, immunocompetence, or pulmonary function. CONCLUSION: No clinically important differences in cardiovascular and systemic response were observed between patients undergoing CO2 or gasless laparoscopy for colonic disease.

Changes in plasma potassium concentration during carbon dioxide pneumoperitoneum.

Hyperkalaemia with ECG changes had been noted during prolonged carbon dioxide pneumoperitoneum in pigs. We have compared plasma potassium concentrations during surgery in 11 patients allocated randomly to undergo either laparoscopic or open appendectomy and in another 17 patients allocated randomly to either carbon dioxide pneumoperitoneum or abdominal wall lifting for laparoscopic colectomy. Despite an increasing metabolic acidosis, prolonged carbon dioxide pneumoperitoneum resulted in only a slight increase in plasma potassium concentrations, which was both statistically and clinically insignificant. Thus hyperkalaemia is unlikely to develop in patients with normal renal function undergoing carbon dioxide pneumoperitoneum for laparoscopic surgery.

Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis.

OBJECTIVE: To study the incidence of late deep venous thrombosis (DVT), and to evaluate a regimen of prolonged thromboprophylaxis after general surgery. DESIGN: Randomised, controlled, open trial, with blinded evaluation. SETTING: University hospital, Denmark. SUBJECTS: 176 consecutive patients undergoing major elective abdominal or non-cardiac thoracic operations, of whom 118 were eligible for evaluation. INTERVENTIONS: Thromboprophylaxis with a low-molecular-weight heparin, tinzaparin, given for four weeks (n = 58), compared with one week (control group, n = 60). MAIN OUTCOME MEASURES: Presence of DVT established by bilateral venography four weeks after the operation. RESULTS: The incidence of late DVT in the control group was 6/60 (10%, 95% confidence interval (CI) 4% to 21%). In the prophylaxis group it was 3/58 (5.2%, 95% CI 1% to 14%) (p = 0.49). CONCLUSION: Prolonged thromboprophylaxis had no significant effect on the incidence of DVT occurring late after general surgery.

[Laparoscopic cholecystectomy in patients with earlier laparotomy]. / Laparoskopisk kolecystektomi hos patienter med tidligere laparotomi.

Previous abdominal surgery has been reported as a relative contraindication to laparoscopic cholecystectomy. A retrospective analysis of 356 laparoscopic cholecystectomies was undertaken to determine whether previous abdominal surgery led to increased morbidity. The results of 116 patients who had had previous abdominal surgery were compared with those of 240 patients without previous abdominal surgery. The rate of conversion to open operation was not increased. The operating time was a little increased. There were no increases in either minor or major postoperative complications in patients with previous abdominal surgery, and the in-hospital stay time was the same. The median recovery time was respectively ten versus eight days in patients with and without previous surgery. We conclude that previous abdominal surgery is not a contraindication to laparoscopic cholecystectomy.

Colour Doppler flow imaging ultrasonography versus venography as screening method for asymptomatic postoperative deep venous thrombosis.

OBJECTIVE: To evaluate colour Doppler flow imaging ultrasonography (CDFI), compared with venography, as a screening method for postoperative deep venous thrombosis (DVT) in a clinical trial on thromboprophylaxis. METHODS: Patients undergoing major abdominal or thoracic surgery were prospectively screened for DVT by CDFI. Patients were examined preoperatively, and on post-operative days 1, 3, 7, 14, 21, and 28. When the CDFI was positive venography was performed. Bilateral venography was performed on day 28 in all patients. The study group comprised 82 patients who underwent CDFI and venography on the same day: four because of suspected DVT (positive CDFI), and 78 on day 28 according to protocol. RESULTS: DVT was detected by venography in seven patients, in three of whom CDFI was positive. CDFI was falsely positive in one case. There were two popliteal and five calf DVTs, of which CDFI detected one and two, respectively. The sensitivity of CDFI was 43%, the specificity 99%. The PVpos for CDFI was 75%, and the PVneg 96%. CONCLUSION: Due to low sensitivity, CDFI cannot stand alone as a screening method for asymptomatic postoperative DVT.

[Mesenteric venous thrombosis]. / Mesenteriel venetrombose.

Mesenteric venous thrombosis (MVT) is a serious though rare abdominal disease. MVT often takes a subacute course with non-specific symptoms. The absence of simple and precise diagnostic tools result in delayed start of treatment and high mortality. Through information retrieval we have here given an overview of the incidence, etiology, pathophysiology, symptomatology, diagnosis, treatment and prognosis of MVT.

Palliation of rectosigmoid neoplasms with Nd:YAG laser treatment.

PURPOSE: The aim of this study was to evaluate the effect of Nd:YAG laser treatment as palliation for rectosigmoid neoplasms. METHODS: Indications for laser therapy, the degree and duration of symptom relief, complication rate, and survival time were recorded in consecutive patients. RESULTS: Seventy-four patients entered the study. Poor general health in older patients, and disseminated or complicating disease were the most frequent indications for therapy. Fifty-five (74 percent) patients experienced good symptomatic effect from the treatment. Six complications occurred: five cases of perforation and one case of moderate bleeding. There was no mortality. The median survival was seven months (range, 14 days-39 months). CONCLUSION: Laser treatment is a good palliative method in patients with colorectal cancer, especially in patients with local recurrence or symptoms from non-resected tumors.

[Palliative treatment of rectal and sigmoid cancer with Nd-YAG laser]. / Palliativ behandling af rectum- og sigmoideumcancer med Nd-YAG-laser.

Nd-YAG laser treatment was employed as palliative treatment in 47 patients with colorectal cancer. Thirty-eight patients (81%) experienced good symptomatic effect from the treatment. Four complications occurred: three cases of perforation and one case of moderate bleeding. There was no mortality. It is concluded that laser treatment is a good palliative method in patients with colorectal cancer, especially in elderly patients with complicating diseases and in patients with local recurrence or symptoms from nonresected tumours.

[Complications and costs of indwelling catheters]. / Komplikationer og omkostninger ved kateter à demeure.

The complication rate and morbidity were registered in a group of 53 outpatients with indwelling catheters. The complication rate is found to be high, especially for patients with catheters on account og incontinence. It is also demonstrated that the transportation costs for the out-patients are high. It is recommended that ordinary changes of the catheter are carried out by specially trained "homenurses" if possible. The indications for indwelling catheter should regularly be reconsidered as needs and suitable measures are constantly changing.

[Tuberculous appendicitis]. / Tuberkuløs appendicitis.

A case of probable tuberculous appendicitis and associated pulmonary tuberculosis is reported. The latest literature concerning abdominal tuberculosis is reviewed.

[Bicycle accidents in preschool children]. / Cykelulykker blandt før-skolebørn.

During the period from June 1st 1984 to May 31st 1987, 108 bicycle accidents were registered among children aged 0-6 years in the Emergency Department, Sundby Hospital. In 95 of the accidents, the child was riding the bicycle. The majority of the accidents were solo accidents where the child fell with the bicycle. 64% had head injuries and 11% of these were hospitalized for observation for concussion. Interviews made at the local nursery schools and play groups revealed that all children over the age of four years owned bicycles. Only 2% of the children employed bicycle helmets. The use of helmets by children is recommended. These should preferably also provide tooth protection.

Leiomyomas of the small intestine: a rare cause of abdominal emergency. Case report.

Two cases of spontaneous perforation of small bowel leiomyomas are discussed, one previously asymptomatic, the other with a single episode of hematemesis two years earlier. Perforation of these tumours is rarely seen. Selective visceral angiography seems to be the most sensitive radiologic examination. New types of enteroscopes are being developed.