Katie Adams

BACKGROUND: Endobronchial ultrasound (EBUS) with transbronchial needle aspiration (TBNA) is becoming widely used for mediastinal lymph node staging in patients with known or suspected lung cancer. While a substantial number of case series have evaluated test performance of this investigation, the small sample sizes limited the ability to accurately evaluate the precision of EBUS-TBNA as a staging modality. A systematic review was performed of published studies evaluating EBUS-TBNA for mediastinal lymph node staging to ascertain the pooled sensitivity and specificity of this investigation. METHODS: A literature search was constructed and performed by a professional medical librarian to identify the literature from 1960 to February 2008. Pooled specificity and sensitivity was estimated from the extracted data with an exact binomial rendition of the bivariate mixed-effects regression model. RESULTS: Of 365 publications, 25 were identified in which EBUS-TBNA was specifically focused on mediastinal node staging. Of these, only 10 had data suitable for extraction and analysis. The overall test performance was excellent with an area under the summary receiver operating characteristics curve of 0.99 (95% CI 0.96 to 1.00); similarly, EBUS-TBNA had excellent pooled specificity of 1.00 (95% CI 0.92 to 1.00) and good pooled sensitivity of 0.88 (95% CI 0.79 to 0.94). CONCLUSIONS: EBUS-TBNA has excellent overall test performance and specificity for mediastinal lymph node staging in patients with lung cancer. The results compare favourably with published results for computed tomography and positron emission tomography.

OBJECTIVES: Abdominal wall hernias are common. Various authors all quote the following order (in decreasing frequency): inguinal, femoral, umbilical followed by rarer forms. But are these figures outdated? We investigated the epidemiology of hernia repair (retrospective review) over 30 years to determine whether the relative frequencies of hernias are evolving. DESIGN: All hernia repairs undertaken in consecutive adult patients were assessed. Data included: patient demographics; hernia type; and operation details. Data were analysed using Microsoft Excel 2007 and SPSS. SETTING: A SINGLE UNITED KINGDOM HOSPITAL TRUST DURING THREE PERIODS: 1985-1988; 1995-1998; and 2005-2008. MAIN OUTCOME MEASURES: Frequency data of different hernia types during three time periods, patient demographic data. RESULTS: Over the three time periods, 2389 patients underwent 2510 hernia repairs (i.e. including bilateral and multiple hernias in a single patient). Inguinal hernia repair was universally the commonest hernia repair, followed by umbilical, epigastric, para-umbilical, incisional and femoral, respectively. Whereas femoral hernia repair was the second commonest in the 1980s, it had become the fifth most common by 2005-2008. While the proportion of groin hernia repairs has decreased over time, the proportion of midline abdominal wall hernias has increased. CONCLUSION: THE CURRENT RELATIVE FREQUENCY OF DIFFERENT HERNIA REPAIR TYPE IS: inguinal; umbilical; epigastric; incisional; para-umbilical; femoral; and finally other types e.g. spigelian. This contrasts with hernia incidence figures quoted in common reference books.

We evaluated the immediate causes of death in 54 adults who underwent an autopsy and were diagnosed as having died of the acquired immunodeficiency syndrome between April 1980 and October 1983. The study group included 25 Haitians, 19 homosexual men, five intravenous drug abusers, two hemophiliacs (type A), and three with no known risk. Fourteen died of central nervous system diseases: 11 of Toxoplasma encephalitis, one of progressive multifocal leukoencephalopathy, one of viral encephalitis, and one of intracerebral hemorrhage. Thirty died of respiratory failure; 16 of Pneumocystis carinii pneumonia, ten of cytomegalovirus pneumonia, one of multiple infections, one of interstitial pneumonia, and two of bacterial pneumonia. Two died of overwhelming generalized infections: one of Mycobacterium avium-intracellulare and one of listeriosis. Six died of disseminated Kaposi's sarcoma, while the remaining two persons died of Toxoplasma myocarditis (one) and one of shock resulting from a percutaneous liver biopsy, respectively. There were differences in the immediate causes of death between Haitians and homosexuals as follows: 63% of homosexual men died of either P carinii pneumonia or Kaposi's sarcoma vs 20% of Haitians. In contrast, 72% of Haitians died of other opportunistic infections as compared with 21% of homosexuals. There has not been an increase in the proportion of cases diagnosed premortem since 1982 and overall, only 32 (58%) were diagnosed premortem; the rest were diagnosed only at autopsy. This study provided evidence that 42% died of currently untreatable diseases.

OBJECTIVE: Decisions made during electronic health record (EHR) implementations profoundly affect usability and safety. This study aims to identify gaps between the current literature and key stakeholders' perceptions of usability and safety practices and the challenges encountered during the implementation of EHRs. MATERIALS AND METHODS: Two approaches were used: a literature review and interviews with key stakeholders. We performed a systematic review of the literature to identify usability and safety challenges and best practices during implementation. A total of 55 articles were reviewed through searches of PubMed, Web of Science and Scopus. We used a qualitative approach to identify key stakeholders' perceptions; semi-structured interviews were conducted with a diverse set of health IT stakeholders to understand their current practices and challenges related to usability during implementation. We used a grounded theory approach: data were coded, sorted, and emerging themes were identified. Conclusions from both sources of data were compared to identify areas of misalignment. RESULTS: We identified six emerging themes from the literature and stakeholder interviews: cost and resources, risk assessment, governance and consensus building, customization, clinical workflow and usability testing, and training. Across these themes, there were misalignments between the literature and stakeholder perspectives, indicating major gaps. DISCUSSION: Major gaps identified from each of six emerging themes are discussed as critical areas for future research, opportunities for new stakeholder initiatives, and opportunities to better disseminate resources to improve the implementation of EHRs. CONCLUSION: Our analysis identified practices and challenges across six different emerging themes, illustrated important gaps, and results suggest critical areas for future research and dissemination to improve EHR implementation.