Enterprise Imaging Governance: HIMSS-SIIM Collaborative White Paper.

Enterprise imaging governance is an emerging need in health enterprises today. This white paper highlights the decision-making body, framework, and process for optimal enterprise imaging governance inclusive of five areas of focus: program governance, technology governance, information governance, clinical governance, and financial governance. It outlines relevant parallels and differences when forming or optimizing imaging governance as compared with other established broad horizontal governance groups, such as for the electronic health record. It is intended for CMIOs and health informatics leaders looking to grow and govern a program to optimally capture, store, index, distribute, view, exchange, and analyze the images of their enterprise.

Upregulation of the EGFR/MEK1/MAPK1/2 signaling axis as a mechanism of resistance to antiestrogen­induced BimEL dependent apoptosis in ER+ breast cancer cells.

The epidermal growth factor receptor (EGFR) is commonly upregulated in multiple cancer types, including breast cancer. In the present study, evidence is provided in support of the premise that upregulation of the EGFR/MEK1/MAPK1/2 signaling axis during antiestrogen treatment facilitates the escape of breast cancer cells from BimEL­dependent apoptosis, conferring resistance to therapy. This conclusion is based on the findings that ectopic BimEL cDNA overexpression and confocal imaging studies confirm the pro­apoptotic role of BimEL in ERα expressing breast cancer cells and that upregulated EGFR/MEK1/MAPK1/2 signaling blocks BimEL pro­apoptotic action in an antiestrogen­resistant breast cancer cell model. In addition, the present study identified a pro­survival role for autophagy in antiestrogen resistance while EGFR inhibitor studies demonstrated that a significant percentage of antiestrogen­resistant breast cancer cells survive EGFR targeting by pro­survival autophagy. These pre­clinical studies establish the possibility that targeting both the MEK1/MAPK1/2 signaling axis and pro­survival autophagy may be required to eradicate breast cancer cell survival and prevent the development of antiestrogen resistance following hormone treatments. The present study uniquely identified EGFR upregulation as one of the mechanisms breast cancer cells utilize to evade the cytotoxic effects of antiestrogens mediated through BimEL­dependent apoptosis.

Windscreen wiper fluid without added screenwash in motor vehicles: a newly identified risk factor for Legionnaires' disease.

A source of infection is rarely identified for sporadic cases of Legionnaires' disease. We found that professional drivers are five times more commonly represented among community acquired sporadic cases in England and Wales than expected. We therefore investigated possible risk exposures in relation to driving or spending time in a motor vehicle. A case control study including all surviving community acquired sporadic cases in England and Wales with onset between 12 July 2008 and 9 March 2009 was carried out. Cases were contacted by phone and controls were consecutively recruited by sequential digital dialling matched by area code, sex and age group. Those who consented were sent a questionnaire asking questions on driving habits, potential sources in vehicles and known risk factors. The results were analysed using logistic regression. 75 cases and 67 controls were included in the study. Multivariable analysis identified two exposures linked to vehicle use associated with an increased risk of Legionnaires' disease: Driving through industrial areas (OR 7.2, 95%CI 1.5-33.7) and driving or being a passenger in a vehicle with windscreen wiper fluid not containing added screenwash (OR 47.2, 95%CI 3.7-603.6). Not adding screenwash to windscreen wiper fluid is a previously unidentified risk factor and appears to be strongly associated with community acquired sporadic cases of Legionnaires' disease. We estimated that around 20% of community acquired sporadic cases could be attributed to this exposure. A simple recommendation to use screenwash may mitigate transmission of Legionella bacteria to drivers and passengers.

Aiming to improve care of older adults: an innovative faculty development workshop.

INTRODUCTION/AIMS: Internists care for older adults and teach geriatrics to trainees, but they often feel ill-prepared for these tasks. The aims of our 1-day Continuing Medical Education workshop were to improve the knowledge and self-perceived competence of general internists in their care of older adults and to increase their geriatrics teaching for learners. SETTING: Two internal medicine training programs encompassing University, Veterans Affairs, and a community-based hospital in Portland, OR, USA. PROGRAM DESCRIPTION: Course faculty identified gaps in assessment of cognition, function, and decisional capacity; managing care transitions; and treatment of behavioral symptoms. To address these gaps, our workshop provided geriatric content discussions followed by small group role plays to apply newly learned content. Forty teaching faculty participated. PROGRAM EVALUATION: Participants completed 13-item multiple-choice pre- and post-workshop geriatric knowledge tests, pre- and post-workshop surveys of self-perceived competence to care for older adults, and completed an open-ended 'commitment to change' prompt after the intervention. Knowledge scores improved following the intervention (61% to 72%, p < .0001), as did self-perceived competence (11 of 14 items significant). Seventy-one percent of participants reported success in meeting their commitment to change goals. DISCUSSION: A 1-day intervention improved teaching faculty knowledge and self-perceived competence to care for older patients and led to self-perceived changes in teaching behaviors.

Managing chronic, nonhealing wounds using a research-based protocol.

The physical, emotional, and financial costs of caring for patients with chronic, nonhealing leg wounds are substantial. In fiscal year 2001, the home care department of a large Veterans Affairs medical center in the Pacific Northwest spent nearly half of its annual budget on veterans needing wound care. In this article, the authors describe a practice improvement project designed to improve the wound care management of homebound veterans with chronic, nonhealing lower extremity wounds using a research-based protocol and consultation by a certified wound care specialist, as well as the effect of this program on home care expenditures.

Uncovering frustrations. A qualitative needs assessment of academic general internists as geriatric care providers and teachers.

BACKGROUND: General internists commonly provide medical care for older adults and geriatric education to trainees, but lack the necessary knowledge and skills to fulfill these tasks. OBJECTIVE: Assess the geriatric training needs of academic general internists in 3 hospital systems in Portland, OR. DESIGN: Ten focus groups and 1 semi-structured interview. Interview transcripts were analyzed using thematic analysis, a well-recognized qualitative technique. PARTICIPANTS: A convenience sample of 22 academic general internists and 8 geriatricians from 3 different teaching hospitals. MEASUREMENTS: We elicited stories of frustration and success in caring for elderly patients and in teaching about their care. We asked geriatricians to recount their experiences as consultants to general internists and to comment on the training of Internists in geriatrics. RESULTS: In addition to deficits in their medical knowledge and skills, our Internists reported frustration with the process of delivering care to older adults. In particular, they felt ill prepared to guide care transitions for patients, use multidisciplinary teams effectively, and were frustrated with health care system issues. Additionally, general internists' approach to medical care, which largely relies on the medical model, is different from that of geriatricians, which focuses more on social and functional issues. CONCLUSIONS: Although our findings may not be broadly representative, improving our general internists' abilities to care for the elderly and to teach learners how to do the same should address deficits in medical knowledge and skills, barriers to the processes of delivering care, and philosophical approaches to care. Prioritizing and quantifying these needs and measuring the effectiveness of curricula to address them are areas for future research.

Infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons.

The common occurrence and dire consequences of infectious disease outbreaks in nursing homes often go unrecognized and unappreciated. Nevertheless, these facilities provide an ideal environment for acquisition and spread of infection: susceptible residents who share sources of air, food, water, and health care in a crowded institutional setting. Moreover, visitors, staff, and residents constantly come and go, bringing in pathogens from both the hospital and the community. Outbreaks of respiratory and gastrointestinal infection predominate in this setting, but outbreaks of skin and soft-tissue infection and infections caused by antimicrobial-resistant bacteria also occur with some frequency.

Travel associated legionellosis among European tourists in Spain - a comment from the EWGLI coordinating centre.

This interesting paper has analysed the data on cases of legionellosis associated with travel to Spain and highlighted some issues which are relevant to the European Working Group for Legionella Infections (EWGLI) surveillance system, eg the reporting of

Travel associated legionnaires disease in Europe: 1997 and 1998.

The European Surveillance Scheme for Travel Associated Legionnaires Disease was set up by the European Working Group on Legionella Infections (EWGLI) in 1987 to identify cases of legionella infection in returning travellers and to detect outbreaks and cl

EWGLI: a European surveillance scheme for travel associated legionnaire s disease.

The European Working Group for Legionella Infections (EWGLI) was set up in 1986 and introduced the European Surveillance Scheme for Travel Associated Legionnaires Disease in 1987. The microbiologists working in reference laborat-ories and the epidemiolog

European surveillance of travel associated legionnaires' disease 1996.

The European Surveillance Scheme for Travel Associated Legionnaires' Disease was established in 1987 to identify clusters and outbreaks of cases of the disease. Twenty-nine collaborating centres in 25 countries contribute case reports in a standard format

Investigation of outbreaks: epidemiology.

Outbreaks of Legionnaires' disease create high levels of public anxiety and media interest and inevitably consume a great deal of public health resources. Investigations should begin as early as possible in order to rapidly identify suspected sources of infection, control the outbreak and prevent further cases occurring. The investigations should be coordinated by an outbreak control team who work collaboratively within local/national/international public health guidelines and with clear terms of reference. The actions carried out by epidemiologists when investigating community-, hospital-, or travel-associated outbreaks are comprehensively outlined in this chapter. The microbiological and environmental actions that complement this work are discussed in the accompanying chapters.

Bacterial and viral infections associated with influenza.

Influenza-associated bacterial and viral infections are responsible for high levels of morbidity and death during pandemic and seasonal influenza episodes. A review was undertaken to assess and evaluate the incidence, epidemiology, aetiology, clinical importance and impact of bacterial and viral co-infection and secondary infection associated with influenza. A review was carried out of published articles covering bacterial and viral infections associated with pandemic and seasonal influenza between 1918 and 2009 (and published through December 2011) to include both pulmonary and extra-pulmonary infections. While pneumococcal infection remains the predominant cause of bacterial pneumonia, the review highlights the importance of other co- and secondary bacterial and viral infections associated with influenza, and the emergence of newly identified dual infections associated with the 2009 H1N1 pandemic strain. Severe influenza-associated pneumonia is often bacterial and will necessitate antibiotic treatment. In addition to the well-known bacterial causes, less common bacteria such as Legionella pneumophila may also be associated with influenza when new influenza strains emerge. This review should provide clinicians with an overview of the range of bacterial and viral co- or secondary infections that could present with influenza illness.

Wet cooling systems as a source of sporadic Legionnaires' disease: a geographical analysis of data for England and Wales, 1996-2006.

BACKGROUND: The source of infection for most sporadic cases of Legionnaires' disease remains unknown. This study aims quantify the relationship between cases and wet cooling systems (WCS), a potential source of aerosolised legionella bacteria. METHODS: The study analysed data on 1163 sporadic, community-acquired cases of Legionnaires' disease in England and Wales with onset between 1996 and 2006, and 11630 postcode controls randomly sampled in proportion to population size and matched on region, age group and sex. The relationship between risk of Legionnaires' disease and distance from a WCS was analysed by conditional logistic regression. RESULTS: Cases and controls had a mean age of 56.3 years; 79.3% were male. Cases lived appreciably closer to WCS than their controls (mean distance of cases=2.11 km, controls=2.58 km; mean difference 0.47 km (95% CI 0.28 to 0.65)). The OR for disease within 1 km of a WCS compared with over 6 km (a distance taken to reflect background rates of Legionnaires' disease) was 1.59 (95% CI 1.26 to 2.01) when adjusted for socio-economic deprivation, and 1.33 (95% CI 1.04 to 1.71) when additionally adjusted for population density. The results suggest that residential proximity to a WCS may account for 19.6% of sporadic community-acquired cases. CONCLUSIONS: WCS may be an important source of sporadic, community-acquired cases of Legionnaires' disease, an observation that has important implications for health protection, especially given the likely increase in such systems as a component of strategies to improve energy efficiency in buildings.

Program at home: a Veterans Affairs Healthcare Program to deliver hospital care in the home.

The Portland Veterans Affairs Medical Center (PVAMC) participated in a research-based National Demonstration and Evaluation Study of Hospital at Home Care for Elderly Patients. PVAMC continued hospital at home care in a modified form based on the results of that research phase and feedback from patients, families, and staff. The modified clinical program (referred to as Program @ Home) provided care for the same diagnoses (exacerbation of congestive heart failure, exacerbation of chronic obstructive pulmonary disease, community-acquired pneumonia, cellulitis) but differed from the research-based demonstration project in that it accepted patients of all ages, accepted early-discharge patients from the hospital, and provided a less-intensive physician and nursing model. In the first 42 months, 290 patients were admitted; 23% came from the emergency room, 54% were early hospital discharge, and the remainder came from an outpatient clinic or home care. Average length of stay was 3.2 days, and 37% were younger than 65. The results describe how a home hospital program has been integrated into the clinical care offerings of a managed care health system and how it supports inpatient, primary, emergency, and home care programs.

From development to success: the European surveillance scheme for travel associated Legionnaires' disease.

BACKGROUND: EWGLINET, the European surveillance scheme for travel associated Legionnaires' disease, was established in 1987 following the identification of the disease in 1976. In 1998, the European Commission's Decision 2119/98/EC provided a legal framework for EWGLINET's operation, and its aims and objectives were formalised. Since its inception, the scheme has encountered a number of challenges which have influenced its development as a Disease Specific Network. The solutions to these challenges, and their successes, may be of interest to similar schemes. AIM: This article traces the development of the scheme and its responses to the challenges it has encountered. RESULTS: One especially significant document developed by the scheme is the European Guidelines for Control and Prevention of Travel Associated Legionnaires' Disease;(1) its history is explored. In addition, EWGLINET's relationship with collaborating centres and other groups such as tour operators is highlighted. CONCLUSIONS: Despite changing over time, the collaborations and partnerships have been maintained and continue to ensure a close cooperation, maximizing public health effects.