Lessons learned from a comprehensive electronic patient record procurement process-implications for healthcare organisations.

BACKGROUND: This study describes learning from procurement of a comprehensive electronic patient record (EPR/electronic health record (EHR)), system for a specialist clinical academic institution. METHOD: Retrospective review of procurement process in addition to evaluation of peer-reviewed literature in the field. RESULTS: Main lessons learned include the importance of detailed preparation of organisational requirements/specifications and organisational 'readiness'. Early staff involvement, resulting in ownership of the selected system by the organisation was a key achievement. The scoring process used required significant resource commitment but, despite being extensive in scope, provided relatively poor distinction between suppliers, despite significant variation in supplier self-scoring. Other elements, such as demonstrations and site visits, provided superior evaluation of functional abilities, and specification requirements should be regarded as threshold evaluation. CONCLUSION: While principles should be followed, the procurement process must be modified to meet the needs of the specific organisation, in terms of its clinical activities, digital maturity, existing infrastructure and budget.

Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal growth restriction at autopsy.

OBJECTIVE: According to the classification system used, 15-60% of stillbirths remain unexplained, despite undergoing recommended autopsy examination, with variable attribution of fetal growth restriction (FGR) as a cause of death. Distinguishing small-for-gestational age (SGA) from pathological FGR is a challenge at postmortem examination. This study uses data from a large, well-characterized series of intrauterine death autopsies to investigate the effects of secondary changes such as fetal maceration, intrauterine retention and postmortem interval on body weight. METHODS: Autopsy findings from intrauterine death investigations (2005-2013 inclusive, from Great Ormond Street Hospital and St George's Hospital, London) were collated into a research database. Growth charts published by the World Health Organization were used to determine normal expected weight centiles for fetuses born ≥ 24 weeks' gestation, and the effects of intrauterine retention (maceration) and postmortem interval were calculated. RESULTS: There were 1064 intrauterine deaths, including 533 stillbirths ≥ 24 weeks' gestation with a recorded birth weight. Of these, 192 (36%) had an unadjusted birth weight below the 10th centile and were defined as SGA. The majority (86%) of stillborn SGA fetuses demonstrated some degree of maceration, indicating a significant period of intrauterine retention after death. A significantly greater proportion of macerated fetuses were present in the SGA population compared with the non-SGA population (P = 0.01). There was a significant relationship between increasing intrauterine retention interval and both more severe maceration and reduction in birth weight (P < 0.0001 for both), with an average artifactual reduction in birth weight of around -0.8 SD of expected weight. There was an average 12% reduction in fetal weight between delivery and autopsy and, as postmortem interval increased, fetal weight loss increased (P = 0.0001). CONCLUSION: Based on birth weight alone, 36% of stillbirths are classified as SGA. However, fetuses lose weight in utero with increasing intrauterine retention and continue to lose weight between delivery and autopsy, resulting in erroneous overestimation of FGR. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Rhabdomyosarcoma subtyping by immunohistochemical assessment of myogenin: tissue array study and review of the literature.

Myogenin immunostaining has been described as a useful marker of the alveolar subtype of rhabdomyosarcoma and as a tool for distinguishing it from the more common embryonal subtype. To add to the growing body of literature describing this phenomenon we analysed myogenin immunohistochemical staining in 152 tumors using a rhabdomyosarcoma tissue array. Results were analysed blinded to histological type by two independent investigators. Samples were excluded if any samples failed to stain with desmin and/or myogenin. Mean percentage of myogenin positive cells was significantly greater for ARMS (n = 31; mean percentage positivity 59% (95% confidence intervals +/- 7%) than ERMS (n = 41, mean percentage positivity 16%, 95% confidence intervals +/- 4; P < 0.0001). This data is consistent with previously published studies identifying strong nuclear myogenin staining in a high proportion of cells as a marker of alveolar histology.

Myogenin and desmin immunohistochemistry in the assessment of post-chemotherapy genitourinary embryonal rhabdomyosarcoma: prognostic and management implications.

PURPOSE: Posttreatment genitourinary embryonal rhabdomyosarcoma often shows well differentiated rhabdomyoblasts, which are detectable on routine histological staining. Definite areas of residual undifferentiated rhabdomyosarcoma indicate residual/recurrent disease. However, the recent use of immunohistochemical staining with desmin and myogenin in resected specimens and surveillance biopsies following adjuvant therapy may demonstrate scant positive staining cells that appear undifferentiated on light microscopy. To our knowledge the clinical significance of this finding is currently unknown. Therefore, we reviewed our retrospective experience with genitourinary embryonal rhabdomyosarcoma to examine the relationship between immunostain positive undifferentiated cells and subsequent clinical outcome. MATERIALS AND METHODS: A total of 14 children with a median age of 2.75 years (range 8 months to 7 years) with genitourinary embryonal rhabdomyosarcoma were identified in the histopathology database. All had biopsy confirmation of the diagnosis, followed by multi-agent chemotherapy. Two children in whom there was obvious residual active tumor at the resection margins were excluded from further analysis. Histopathological findings in all patients on the resection/posttreatment biopsy were reviewed. All specimens were immunostained with desmin and myogenin to detect residual undifferentiated rhabdomyoblasts. The relation between histopathological findings and outcome was determined. RESULTS: There were 14 cases of genitourinary embryonal rhabdomyosarcoma. In 2 cases (14%) residual embryonal tumor was pathologically confirmed following initial treatment. In 12 cases no obvious residual tumor was present following initial therapy. Rhabdomyosarcoma affected the bladder in 10 cases and the vagina in 2. There were no distant metastases in any child. Ten patients underwent local resection following chemotherapy and 2 underwent followup biopsies only without resection. A total of 11 cases showed well differentiated, posttreatment rhabdomyoblasts that was identifiable on routine hematoxylin and eosin staining with margins apparently free of tumor and 1 showed no morphological evidence of residual rhabdomyosarcoma. However, all cases demonstrated at least scant abnormal desmin and myogenin positive cells in the specimens. Four patients had no further treatment and none had clinical recurrence. All were well 10 years (range 8 to 13) after treatment. Eight patients received further treatment (chemotherapy and/or radiotherapy) based on clinical and pathological findings, followed by further resection in 3. One patient died of disease but 7 were well a median of 7.2 years (range 8 months to 13 years) after treatment. CONCLUSIONS: The significance of undifferentiated myogenin/desmin positive cells in genitourinary embryonal rhabdomyosarcoma in the absence of morphological residual/recurrent embryonal rhabdomyosarcoma remains unclear since such cells can be detected in all cases of posttreatment embryonal rhabdomyosarcoma. In some cases findings are associated with clinical disease recurrence, while others with identical histopathological findings following initial treatment have no clinical sequelae even in the absence of further treatment. In genitourinary embryonal rhabdomyosarcoma close and regular clinical surveillance is essential. Desmin/myogenin immunohistochemistry to detect scattered undifferentiated cells does not appear to provide useful prognostic information.

Intertwin disparity in fetal size in monochorionic and dichorionic pregnancies.

OBJECTIVE: To compare monochorionic and dichorionic pregnancies for intertwin disparities in fetal size. METHODS: Monochorionic and dichorionic pregnancies, recruited from an ultrasound screening study at 10-14 weeks' gestation, were compared for intertwin disparities in crown-rump length and birth weight. The disparities were expressed as a percentage of the values of the larger twin. RESULTS: The study population was 123 monochorionic and 416 dichorionic twin pregnancies. In the 104 monochorionic and 381 dichorionic pregnancies resulting in two live births, there were no significant differences in median (range) intertwin disparity in crown-rump length (4.3% [0-18.8%] and 3.4% [0-25.5%]) or birth weight (10.2% [0-37.0%] and 9.3% [0-49.2%]). To determine that the observed 0.9% intertwin differences in crown-rump length and birth weight between the two groups were significant at alpha = .05 with 80% power, we would have had to examine a minimum of 984 and 926 twin pregnancies, respectively, assuming that the proportion of monochorionic to dichorionic twins remained the same as in the current study. In addition, there was no significant correlation between intertwin disparities in crown-rump length and intertwin disparities in birth weight in either the monochorionic (P = .40, Rho = 0.02, 95% confidence interval [CI] -0.17, 0.22) or dichorionic group (P = .44, Rho = 0.01, 95% CI -0.11, 0.09). The median (range) intertwin disparity in crown-rump length in 15 dichorionic pregnancies with chromosomally abnormal fetuses (6.6% [0-24.0%]) and in 20 dichorionic pregnancies that ended in miscarriage or intrauterine death of one or both fetuses (7.7% [0-43.9%]) was significantly higher than in dichorionic pregnancies resulting in two live births (Z = 2.49 and 3.26, respectively, and P = .01 and .001, respectively). However, in 19 monochorionic twins with adverse pregnancy outcome there was no significant difference in median (range) intertwin disparity in crown-rump length (4.5% [0-20.0%]) from monochorionic pregnancies resulting in two live births (4.3% [0-18.8%]). To determine that the observed 0.2% difference in intertwin difference in crown-rump length between the two groups was significant at alpha = .05 with 80% power we would have had to examine a minimum of 5652 monochorionic twin pregnancies, assuming that the proportion in each group remained the same as in the current study. CONCLUSION: The findings of this study demonstrate that monochorionic and dichorionic twin pregnancies do not differ significantly in intertwin disparity in fetal size, either in early pregnancy or at birth.