Do electronic patient information systems improve efficiency and quality of care? An evaluation of utilisation of the Discovery HealthID application.

BACKGROUND: Electronic health records (EHRs) appear to offer a number of potential benefits, but practitioners are often hesitant to make the transition to using them. OBJECTIVES: To determine whether the use of one such system, designed and offered by a health insurer (HealthID; Discovery Health), makes a difference to the efficiency and quality of doctor-patient consultations. METHODS: A descriptive study using mixed methods was designed. A qualitative phase of individual interviews of purposefully sampled respondents was followed by a quantitative survey of a random sample of general practitioners and specialists who were registered users of the system. RESULTS: In the qualitative findings, 18 respondents reported their perceptions of the ease of use of the application, their motivation for using it, its functions and benefits, the impact on efficiency and quality of care, and the challenges they experienced. In addition, they reported on the details of the challenges of using the system, and made suggestions for improvements, particularly with regard to the need for training and IT support. The quantitative results from the majority of 93 respondents confirmed that while the use of the app improved patient care through positive effects on specific functions such as access to accurate patient records and easier Chronic Illness Benefit applications, they felt that it had an equivocal impact in other areas, such as maintaining patient confidentiality and enhancing teamwork and efficiency. The financial incentives offered by Discovery Health, as well as possibly the training and support provided, appear to be more influential for high-frequency than for low-frequency users. The majority said that it did not help with referrals or script writing, or with access to International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes. CONCLUSIONS: EHR systems like Discovery Health's HealthID could improve the efficiency of medical consultations by increasing access to stored health information without requiring data entry by clinicians, and thereby have the potential to indirectly improve the quality of care, provided that certain conditions are met.

Geant4 physics list comparison for the simulation of phase-contrast mammography (XPulse project).

PURPOSE: Breast cancer is the most frequent cancer in women. Early and accurate detection of the disease is a major factor in patient survival. To this end, phase-contrast imaging has gained significant interest in recent years. The aim of this work was to validate the physics models of a Geant4 mammography imaging simulation (in the context of the XPulse project) by comparing to EGSnrc results. METHODS: We used three Geant4 electromagnetic physics lists of the version 10.4 of the toolkit: Standard, Livermore and Penelope. We calculated energy distributions in homogeneous and inhomogeneous phantoms and breast doses in DICOM images. The simulations used photon beams of energies 20-100 keV. The Geant4 calculations were compared with EGSnrc/DOSXYZnrc simulations. RESULTS: We found a very good agreement between the Standard Electromagnetic option 4 and Livermore Physics Lists (within 1% for all beam energies). Larger differences were found between Standard Electromagnetic option 4 and Penelope Physics Lists (about 4%). The agreement of longitudinal energy distributions between Geant4 Standard Electromagnetic option 4 and EGSnrc was good in water and light biological materials, but important discrepancies were found in heavy elements. We confirmed with both codes that dose to the breast is minimal at beam energy around 60 keV. CONCLUSIONS: Overall, we found good agreement between the option 4 of the Standard Electromagnetic physics list and Livermore physics lists of Geant4, as well as EGSnrc for materials relevant to mammography screening. Further investigations are needed for the case of heavier materials.

Pre- and postoperative radiotherapy for extremity soft tissue sarcoma: Evaluation of inter-observer target volume contouring variability among French sarcoma group radiation oncologists.

PURPOSE: The purpose of this study was to evaluate, during a national workshop, the inter-observer variability in target volume delineation for primary extremity soft tissue sarcoma radiation therapy. METHODS AND MATERIALS: Six expert sarcoma radiation oncologists (members of French Sarcoma Group) received two extremity soft tissue sarcoma radiation therapy cases 1: one preoperative and one postoperative. They were distributed with instructions for contouring gross tumour volume or reconstructed gross tumour volume, clinical target volume and to propose a planning target volume. The preoperative radiation therapy case was a patient with a grade 1 extraskeletal myxoid chondrosarcoma of the thigh. The postoperative case was a patient with a grade 3 pleomorphic undifferentiated sarcoma of the thigh. Contour agreement analysis was performed using kappa statistics. RESULTS: For the preoperative case, contouring agreement regarding GTV, gross tumour volume GTV, clinical target volume and planning target volume were substantial (kappa between 0.68 and 0.77). In the postoperative case, the agreement was only fair for reconstructed gross tumour volume (kappa: 0.38) but moderate for clinical target volume and planning target volume (kappa: 0.42). During the workshop discussion, consensus was reached on most of the contour divergences especially clinical target volume longitudinal extension. The determination of a limited cutaneous cover was also discussed. CONCLUSION: Accurate delineation of target volume appears to be a crucial element to ensure multicenter clinical trial quality assessment, reproducibility and homogeneity in delivering RT. radiation therapy RT. Quality assessment process should be proposed in this setting. We have shown in our study that preoperative radiation therapy of extremity soft tissue sarcoma has less inter-observer contouring variability.

[Lung dose constraints for normo-fractionated radiotherapy and for stereotactic body radiation therapy]. / Doses aux organes à risque en radiothérapie conformationnelle et en radiothérapie stéréotaxique : les poumons.

Radiation-induced lung disease (RILD) is common after radiation therapy and represents cornerstone toxicities after treatment of thoracic malignancies. From a review of literature, the objective of this article was to summarize clinical and non-clinical parameters associated with the risk of RILD in the settings of normo-fractionated radiotherapy and stereotactic body radiation therapy (SBRT). For the treatment of lung cancers with a normo-fractionated treatment, the mean lung dose (MLD) should be below 15-20Gy. For a thoracic SBRT, V20Gy<10% and MLD<6Gy are recommended. One should pay attention to central tumors and respect specific dose constraints to the bronchial tree. The recent technological improvements may represent an encouraging way to decrease lung toxicities. Finally, our team developed a calculator in order to predict the risk of radiation pneumonitis.

Introduction of external magnetic fields in entropic moment modelling for radiotherapy.

One of the big challenges of the emerging MRI-guided radiotherapy is the prediction of an external magnetic field effect on the deposited dose induced by a beam of charged particles. In this paper, we present the results of the implementation of the Lorentz force in the deterministic M1 model. The validation of our code is performed by comparisons with the Monte-Carlo code FLUKA. The relevant examples show a significant modification of the shape of dose deposition volume induced by the external magnetic field in presence of heterogeneities. A gamma-index analysis 3%/3mm shows a good agreement of our model with FLUKA simulations.

Evaluation of Bone Mineral Density in Patients with Type 1 Gaucher Disease in Argentina.

The purpose of this study was to evaluate the frequency of osteoporosis (OP) in patients with Gaucher disease (GD) in Argentina. GD patients from 28 centers were consecutively included from April 2012 to 2014. Bone mineral density (BMD) was determined by dual X-ray absorptiometry in the lumbar spine and the femoral neck or the total proximal femur for patients ≥20 yr of age, and by whole-body scan in the lumbar spine in patients <20 yr of age. In children, mineral density was calculated using the chronological age and Z height. OP diagnosis was determined following adult and pediatric official position of the International Society for Clinical Densitometry. A total of 116 patients were included, of which 62 (53.5%) were women. The median age was 25.8 yr. All patients received enzyme replacement therapy, with a median time of 9.4 yr. Normal BMD was found in 89 patients (76.7%), whereas low bone mass (LBM) or osteopenia was found in 15 patients (13%) and OP in 12 patients (10.3%). The analysis of the pediatric population revealed that 4 patients (9.3%) had LBM and 3 (7%) had OP (Z-score ≤ -2 + fractures height-adjusted by Z), whereas in the adult population (n = 73), 11 patients (15%) had LBM or osteopenia and 9 (12.3%) had OP. Bone marrow infiltration and the presence of fractures were significantly correlated with the presence of OP (p = 0.04 and <0.001, respectively). This is the first study in Argentina and in the region describing the frequency of OP or LBM in GD patients treated with imiglucerase using the official position of the International Society for Clinical Densitometry.

[Radiotherapy for retroperitoneal sarcomas]. / Place de la radiothérapie dans la prise en charge des sarcomes rétropéritonéaux.

The management of retroperitoneal sarcoma can be very challenging, and the quality of initial treatment strategy appears to be a crucial prognostic factor. En bloc surgery is currently the standard of care for these rare tumours and perioperative treatments such as chemotherapy or radiotherapy have not been validated yet. However, local-regional relapse constitutes the most common disease course. While adjuvant radiotherapy is less and less common due to gastrointestinal toxicities, preoperative radiation therapy offers numerous advantages and is being evaluated as part of a national multicentre phase II study (TOMOREP trial) and is the subject of a European randomized phase III study (STRASS trial). The objective of this article is to present data on preoperative irradiation in terms of dose, volumes and optimal radiotherapy techniques for the treatment of this rare disease.

[Management of soft tissues sarcoma of the limbs by external beam radiation therapy]. / Prise en charge des sarcomes des tissus mous des membres par radiothérapie externe.

Soft tissue sarcomas are rare tumours. Conservative surgery followed by postoperative radiation therapy represents the gold standard in the majority of cases. Postoperative radiotherapy improves local control without affecting survival. Besides the quality of surgical excision, which remains the major prognostic factor, the importance of the irradiation volume and particularly margins used in external beam radiotherapy were also found to influence local control of the disease. In this study, we propose to conduct a literature review on the present state of our knowledge on this subject in the form of an articulated controversy: in favour or opposed to large margins in external radiotherapy.

Deterministic model for the transport of energetic particles: Application in the electron radiotherapy.

A new deterministic method for calculating the dose distribution in the electron radiotherapy field is presented. The aim of this work was to validate our model by comparing it with the Monte Carlo simulation toolkit, GEANT4. A comparison of the longitudinal and transverse dose deposition profiles and electron distributions in homogeneous water phantoms showed a good accuracy of our model for electron transport, while reducing the calculation time by a factor of 50. Although the Bremsstrahlung effect is not yet implemented in our model, we propose here a method that solves the Boltzmann kinetic equation and provides a viable and efficient alternative to the expensive Monte Carlo modeling.

[Adaptive radiotherapy in routine: The radiation oncologist's point of view]. / Radiothérapie adaptative en routine : point de vue de l'oncologue radiothérapeute.

Adaptive radiotherapy is defined as all processes leading to the modification of a treatment plan on the basis of patient-specific variations observed during the course of a treatment. This concept is currently of particular relevance due to the development of onboard volumetric imaging systems, which allow for daily viewing of variations in both tumour and organs at risk in terms of position, shape or volume. However, its application in routine clinical practice is limited due to the demanding nature of the processes involved (re-delineation and replanning) and increased dependence on available human resources. Even if "online" strategies, based on deformable image registration (DIR) algorithms, could lead to a reduction in both work and calculation time, for the moment their use is limited to the research field due to uncertainties surrounding the validity of results gathered. Other strategies without DIR can be used as "offline" or "hybrid offline-online" strategies that seem to offer a compromise between time consumption and therapeutic gain for the patient.

French multicentre clinical evaluation of helical TomoTherapy for anal cancer in a cohort of 64 consecutive patients.

PURPOSE/OBJECTIVES: To assess feasibility and toxicity of Helical TomoTherapy for treating anal cancer patients. METHODS: From 2007 to 2011, 64 patients were consecutively treated with TomoTherapy in three centres for locally advanced squamous-cell anal carcinoma (T2 > 4 cm or N positive). Prescribed doses were 45 Gy to the pelvis including inguinal nodes and 59.4 Gy to the primary site and involved nodes with fractions of 1.8 Gy, five days a week. A positional Megavoltage Computed Tomography was performed before each treatment session. All acute and late toxicities were graded according to Common Terminology Criteria for Adverse Events version 3.0. Survival analysis was performed using the Kaplan-Meier method. RESULTS: Median follow-up was 22.9 months. Fifty-four women and 10 men were treated (median age: 62 years). Nineteen patients (29.7%) had T2, 16 patients (25.0%) T3, and 27 patients (42.2%) T4 tumours. Thirty-nine patients (60.9%) had nodal involvement. Median tumour size was 45 mm (range, 10-110 mm). Seven patients had a colostomy before treatment initiation. Fifty-seven patients received concomitant chemotherapy (5-FU/cisplatin or 5-FU/mitomycin-based therapy). Forty-seven patients (73.4 %) experienced a complete response, 13 a partial response or local recurrence, and 11 had salvage surgery; among these, six became complete responders, three experienced metastatic failure, and two local failure. At least four patients experienced metastatic recurrence (concomitant to a local failure for one patient). The two-year overall survival was 85.6% (95 %CI [71.1%-93.0%]), and the one-year disease-free survival, and colostomy-free survival were 68.7% (95 %CI [54.4%-79.4]), and 75.5% (95 %CI [60.7%-85.3%]) respectively. Overall survival, disease-free survival and colostomy free-survival were significantly better for women than men (p = 0.002, p = 0.004, and p = 0.002 respectively). Acute grade ≥3 toxicity included dermatologic (46.9% of patients), gastrointestinal (20.3%), and hematologic (17.2%) toxicity. Acute grade 4 hematologic toxicity occurred in one patient. No grade 5 event was observed. CONCLUSIONS: TomoTherapy for locally advanced anal cancer is feasible. In our three centres of expertise, this technique appeared to produce few acute gastrointestinal toxicities. However, high rates of dermatologic toxicity were observed. The therapeutic efficacy was within the range of expectations and similar to previous studies in accordance with the high rates of locally advanced tumours and nodal involvement.

Frequency of surgery and hospital admissions for communicable diseases in a high- and middle-income setting.

BACKGROUND: In high-income countries, non-communicable diseases drive the demand for surgical healthcare. Middle-income countries face a double disease burden, of both communicable and non-communicable disease. The aim of this study was to describe the role of surgery for the in-hospital care of infectious conditions in the high-income country Sweden and the middle-income country South Africa. METHODS: A retrospective cohort study was performed of 1.4 million infectious disease admissions. The study populations were the entire population of Sweden, and a cohort of 3.5 million South Africans with private healthcare insurance, during a 7-year interval. The outcome measures were frequency of surgical procedures across a spectrum of diseases, and sex and age during the medical care event. RESULTS: Some 8.1 per cent of Swedish and 15.7 per cent of South African hospital admissions were because of infectious disease. The proportion of infectious disease admissions that were associated with surgery was constant over time: 8.0 (95 per cent c.i. 7.9 to 8.1) per cent in Sweden and 21.1 (21.0 to 21.2) per cent in South Africa. The frequency of surgery was 2.6 (2.6 to 2.7) times greater in South Africa, and 2.2 (2.2 to 2.3) times higher after standardization for age, sex and disease category. CONCLUSION: The study suggests that surgical care is required to manage patients with communicable diseases, even in high-income settings with efficient prevention and functional primary care. These results further stress the importance of scaling up functional surgical health systems in low- and middle-income countries, where the disease burden is distinguished by infectious disease.

[Thermoplastic mask in radiotherapy: a source of anxiety for the patient?]. / Le masque de contention en radiothérapie : une source d'anxiété pour le patient ?

PURPOSE: The thermoplastic mask often used to immobilize patients in radiotherapy can cause varying levels of stress and anxiety. This study aimed at evaluating the anxiety related to the use of radiotherapy masks and the coping strategies adopted by patients. PATIENTS AND METHODS: Nineteen patients treated with radiotherapy mask for head and neck cancer, a brain tumour or a lymphoma, were met twice by a psychologist, either after the making of the mask and the first course of radiotherapy, or in the middle and at the end of treatment. Thirty-four semi-structured interviews were treated using a thematic content analysis and 13 patients answered to anxiety (STAI-YB) and coping (WCC) scales. RESULTS: The STAI-YB anxiety scores related to wearing the masks were low during the radiotherapy treatment period, and were confirmed by the remarks of patients recorded during the semi-structured interviews. Most patients had a positive perception of the mask, and considered it as a friend or protection. Twelve out of the 13 patients admitting to anxiety benefited from problem focused coping strategies. CONCLUSIONS: Thermoplastic mask-related anxiety is low and possibly lies in the positive representation patients have about the mask. The explanations provided by health professionals on the radiotherapy mask possibly have a very positive effect on this perception.

[Radiotherapy indications for non-malignant diseases in 2014]. / Indications non oncologiques de la radiothérapie : quelles indications en 2014 ?

This review updates the radiotherapy indications for non-malignant diseases, except those treated by radiosurgery. Since the last 2005 review, there have been no major changes in the indications: the prevention of heteropic bone formation and keloids remain classical indications, while the treatment of macular degeneration or the prevention of coronary restenosis are now past history. Nevertheless, the radiation treatment for benign diseases should have the same criteria as for malignant diseases: information of the patient on risks, benefits and treatment quality.

Adjuvant radiotherapy for extremity and trunk wall atypical lipomatous tumor/well-differentiated LPS (ALT/WD-LPS): a French Sarcoma Group (GSF-GETO) study.

BACKGROUND: The role of adjuvant radiotherapy (RT) in the management of atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WD-LPS) remains controversial. METHODS: Two hundred eighty-three patients with operable ALT/WD-LPS, no history of previous cancer, chemotherapy (CT) or RT, treated between 1984 and 2011 registered in the Conticabase database were included and described. Overall (OS), progression-free survival (PFS) and time to local relapse (TTLR) were evaluated from the time of first treatment. RESULTS: Three of 20 centers enrolled 58% of the patients. Median age at diagnosis was 61 (range 25-94) years, 147 patients (52%) were males, 222 (78%) patients had their primary tumor located in an extremity while 36 (13%) and 25 (9%) had tumors involving the girdle and the trunk wall, respectively. The median size of primary tumors was 17 cm (range 2-48 cm). Adjuvant RT was given to 132 patients (47%). Patients who received adjuvant RT had larger tumors (P = 0.005), involving more often the distal limbs (P < 0.001). Use of adjuvant RT varied across centers and along the study period. Other characteristics were balanced between the two groups. Median follow-up was 61.7 months. None of the patients developed metastasis during follow-up. The 5-year local relapse-free survival rates were 98.3% versus 80.3% with and without adjuvant RT, respectively (P < 0.001). Once stratified on time period (before/after 2003), adjuvant RT, tumor site and margin status (R0 versus other) were independently associated with TTLR. No OS difference was observed (P = 0.105). CONCLUSION: In this study, adjuvant RT following resection of ALT/WD-LPS was associated with a reduction of LR risk.

[Impact of dynamic IMRT and tomotherapy in pelvic cancers: a prospective dosimetric study with 51 patients]. / Apport de la RCMI rotationnelle et de la tomothérapie hélicoïdale dans les cancers pelviens : étude dosimétrique prospective sur 51 patients.

PURPOSE: To compare the dosimetric results of different techniques of dynamic intensity modulated radiation therapy (IMRT) in patients treated for a pelvic cancer with nodal irradiation. PATIENTS AND METHODS: Data of 51 patients included prospectively in the Artpelvis study were analyzed. Thirty-six patients were treated for a high-risk prostate cancer (13 with helical tomotherapy, and 23 with Rapid'Arc(®)) and 15 patients were treated for a localized anal cancer (nine with helical tomotherapy and six with Rapid'Arc(®)). Plan quality was assessed according to several different dosimetric indexes of coverage of planning target volume and sparing of organs at risk. RESULTS: Although some dosimetric differences were statistically significant, helical tomotherapy and Rapid'Arc provided very similar and highly conformal plans. Regarding organs at risk, Rapid'Arc(®) provided better pelvic bone sparing with a lower non-tumoral integral dose. CONCLUSION: In pelvis cancer with nodal irradiation, Rapid'Arc and helical tomotherapy provided very similar plans. The clinical evaluation of Artpelvis study will verify this equivalence hypothesis.

Adherence to consensus-based diagnosis and treatment guidelines in adult soft-tissue sarcoma patients: a French prospective population-based study.

BACKGROUND: Soft-tissue sarcomas (STSs) are rare tumors with varied histological presentations. Management and treatment are thus complex, but crucial for patient outcomes. We assess adherence to adult STS management guidelines across two French regions (10% of the French population). We also report standardized incidence. PATIENTS AND METHODS: STS patients diagnosed from 1 November 2006 to 31 December 2007 were identified from pathology reports, medical hospital records, and cancer registries. Guideline adherence was assessed by 23 criteria (validated by Delphi consensus method), and age and sex-standardized incidence rates estimated. Associations between patient, treatment, and institutional factors and adherence with three major composite criteria relating to diagnostic imaging and biopsy as well as multidisciplinary team (MDT) case-review are reported. RESULTS: Two hundred and seventy-four patients were included (57.7% male, mean age 60.8 years). Practices were relatively compliant overall, with over 70% adherence for 10 criteria. Three criteria with perfect Delphi consensus had low adherence: receiving histological diagnosis before surgery, adequacy of histological diagnosis (adherence around 50% for both), and MDT discussion before surgery (adherence <30%). Treatment outside of specialized centers was associated with lower adherence for all three composite criteria, and specific tumor sites and/or features were associated with lower adherence for diagnostic imaging, methods, and MDT meetings. STS standardized incidence rates were 4.09 (European population) and 3.33 (World) /100 000 inhabitants. CONCLUSIONS: Initial STS diagnosis and treatment across all stages (imaging, biopsy, and MDT meetings) need improving, particularly outside specialized centers. Educational interventions to increase surgeon's sarcoma awareness and knowledge and to raise patients' awareness of the importance of seeking expert care are necessary.

Descriptive epidemiology of CNS tumors in France: results from the Gironde Registry for the period 2000-2007.

An increase in the incidence of CNS tumors has been observed in many countries in the last decades. The reality of this trend has been much debated, as it has happened during a period when computer-assisted tomography and MRI have dramatically improved the detection of these tumors. The Gironde CNS Tumor Registry provides here the first data on CNS tumor incidence and trends in France for all histological types, including benign and malignant tumors, for the period 2000-2007. Incidence rates were calculated globally and for each histological subtype. For trends, a piecewise log-linear model was used. The overall annual incidence rate was found to be 17.6/100 000. Of this rate, 7.9/100 000 were neuroepithelial tumors and 6.0/100 000 were meningiomas. An overall increase in CNS tumor incidence was observed from 2000 to 2007, with an annual percent change (APC) of +2.33%, which was explained mainly by an increase in the incidence of meningiomas over the 8-year period (APC = +5.4%), and also more recently by an increase in neuroepithelial tumors (APC = +7.45% from 2003). The overall increase was more pronounced in women and in the elderly, with an APC peaking at +24.65% in subjects 85 and over. The increase in the incidence rates we observed may have several explanations: not only improvements in registration, diagnosis, and clinical practice, but also changes in potential risk factors.