iPads for Hospitals

To replace hospital charts with iPads is a no brainer, especially when one has watched any episode of any of the Star Trek shows where there's a scene in Sickbay.  The key to using iPads as patient charts is a fully functional, implemented and utilized electronic medical record (EMR), a concept which in the #HealthIT community is easier said than done.

Utilization, among health care personnel especially doctors, has been poor resulting in many EMR projects failing initially.  As the younger crop of doctors are coming in, doctors who grew up with computers, and their allied personal technology, utilization is improving.

One main obstacle to EMR utilization by doctors is the consequent alteration in their respective workflows that the system needs to impose.  Instead of writing on a chart, which you can do standing, sitting, in the patient's room, at the nurse's station, or in the pantry, a traditional EMR required the doctor to sit down on a terminal, usually needing to rewrite what you had written in your tickler, and frequently competing with other doctors, nurses or students who need to use the same terminal.

An iPad that connects to the hospital's WIFI network that accesses the EMR using a web-browser-based interface, gets you as close as possible to complete EMR utilization without altering the doctor's workflow by much.  Being browser-based, this makes it platform independent, allowing the doctor to access the EMR using his smartphone, tablet, or even laptop without any need for customized and installed software or a specific hardware and operating system requirement.

An article showed that one hospital piloted the use of iPads and computed it's return-of-investment (ROI) rate to be 9 days.  These numbers were based on time and motion studies and how clinical workflow impacted labor costs.  In other words, the iPads increased productivity allowing the staff to do more tasks with the same time as compared to their old workflow.

Unfortunately, in this country such a system isn't possible as a Hospital Information and Management System with a full-featured EMR with 100% utilization has not happened and thus an iPad solution won't fly as of yet.

NEW AUA Guidelines for Castration-Resistant Prostate Cancer

During the 2013 Annual Meeting of the American Urological Association, new guidelines for the treatment of Castration-Resistant Prostate Cancer (CRPC).  CRPC has always been a vexing problem to Urologists since Hormone Therapy was developed by Charles Huggins in 1941.  Although quite effective initially, especially for advanced prostate cancer, it had been found that castration or hormone ablation gradually became less effective after several years, and thus the identification of "Hormone-Resistant Prostate Cancer (HRPC)" made.

In recent years, it has been found that HRPC was found to still be quite sensitive to other forms of hormone therapy, in particular, those that interrupt the steroid synthesis pathway at a "higher" level compared to medical or surgical castration.  This also explains why second-line hormone therapies such as estrogens and ketoconazole was found to be somewhat effective. Thus, the term "Castration-Resistant Prostate Cancer" came into being.

With the development of novel new therapies that are still hormonal in nature, the AUA has now released treatment guidelines that focus on six (typical) "index" patients.  These include:

1. Index Patient 1: Asymptomatic, non-metastatic CRPC
2. Index Patient 2: Asymptomatic or minimally symptomatic, mCRPC without prior docetaxel chemotherapy
3. Index Patient 3: Symptomatic, mCRPC with good performance status and no prior chemotherapy
4. Index Patient 4: Symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy
5. Patient 5: Symptomatic, mCRPC with good performance status and prior doxetaxel chemotherapy
6. Index Patient 6: Symptomatic, mCRPC with poor performance status and prior docetaxel chemotherapy

Many clinicians have recognized the importance of releasing such guidelines as in the past, there was lack of cohesion in what exactly would be the best course for these groups of patients.  Most of the time, clinicians would have to wade through tons of research material or attend special symposiums to get some degree of clarity... only to be debunked a few months later.

"Prior to 2004, once patients failed primary androgen deprivation, treatments were administered solely for palliation,"

To read the full text fo the guidelines, visit the website of the American Urological Association or click here.

Yes, we can now PUSH Stones with Ultrasound!

During this year's Annual Meeting of the American Urological Association, one rather interesting State-of-the-Art Lecture delivered on May 7, 2013 by Mike Bailey, Senior Principal Engineer of the Center for Industrial and Medical Ultrasound (CIMU) department of the Applied Physics Laboratory in the University of Washington, showed the ability to PUSH urinary stones using focused bursts of ultrasound directed in the opposite end from where you want the stone to move.

He actually showed videos of stones hopping to and fro experimentally in vitro and in vivo in pig kidneys.  

Urologists will have to learn how to image the kidney stone and how to push it with the device.



Stone in the upper calyx before pushing.

Upper calyx stone is jumping to the pelvis due to ultrasound.

The video demonstrations he showed were actually quite compelling since every Urologist knows the frustration of having the ability to pulverise urinary stones with Extracorporeal Shock Wave Lithotripsy (ESWL) but not able to extract the stones, as opposed to Percutaneous Nephrolithotomy (PCNL) or Ureteroscopy with Stone Basket Extraction (SBE). 

My only concern with this technology is the learning curve for this technology.  Unlike in imaging ultrasound, you merely need to hold the probe in a position that allows you to see the stone.  For SonoMotion, which is probably what this technology will eventually be called, you need to position your probe manually at the side of the stone opposite to the direction you want it to go.  Thus, this requires a good knowledge of the detailed anatomy of the kidney, as well as the specific anatomy of a the patient's kidney.  In my view, this is easier said than done.  That being said, this technology should be closely followed by Urologists with an interest in ESWL.

The State-of-the-Art Lecture presented in the AUA can be viewed here.