Influence of Baseline Platelet Count on Outcomes in Patients With Venous Thromboembolism (from the COMMAND VTE Registry)

The influence of thrombocytopenia on the long-term clinical outcomes has not been thoroughly evaluated in patients with venous thromboembolism (VTE). This study sought to elucidate association of baseline thrombocytopenia with bleeding, recurrent VTE, and mortality risk. We evaluated the influence of baseline thrombocytopenia among 3,012 patients whose baseline platelet counts were available in the COMMAND VTE Registry in Japan with a median follow-up period of 1,219 days. Baseline thrombocytopenia was classified as follows: mild: 100,000 to 150,000/μl; moderate: 50,000 to 99,999/μl; and severe: <50,000/μl. The primary outcome measurement was International Society of Thrombosis and Hemostasis major bleeding, and the secondary outcome measurements were recurrent VTE and all-cause death. There were 167 patients (5.5%) with moderate or severe thrombocytopenia (moderate: 144 patients and severe: 23 patients), 523 patients (17.4%) with mild thrombocytopenia, and 2,322 patients (77.1%) without thrombocytopenia. The cumulative 5-year incidence of major bleeding was markedly higher in patients with moderate or severe thrombocytopenia (moderate or severe 29.4% vs mild: 14.1% vs no thrombocytopenia: 10.6%, p <0.001). After adjusting the confounders, the risk of or thrombocytopenia relative to no thrombocytopenia for major bleeding remained significant (adjusted hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.43 to 3.13, p <0.001). The excess risk of moderate or severe thrombocytopenia relative to no thrombocytopenia was also significant for mortality (adjusted HR 1.54, 95% CI 1.18 to 1.97, p = 0.002), but the risk was neutral for recurrent VTE (adjusted HR 1.05, 95% CI 0.55 to 1.81, p = 0.87). In conclusion, VTE patients with baseline moderate or severe thrombocytopenia had higher risk for major bleeding events and mortality without significant excess risk for recurrent VTE events.

Validation of simplified PESI score for identification of low-risk patients with pulmonary embolism: From the COMMAND VTE Registry

Background:

The simplified pulmonary embolism severity index (sPESI) score has been reported to be useful in predicting 30-day mortality for patients with pulmonary embolism, which helps the identification of low-risk patients for early hospital discharge or home treatment. However, therapeutic decision-making should also be based on the risks of adverse events other than mortality.

Methods:

The COMMAND VTE Registry is a multicentre registry enrolling consecutive patients with acute symptomatic venous thromboembolism in Japan between January 2010 and August 2014, and the current study population consisted of 1715 patients with pulmonary embolism. We calculated the sPESI score for each patient, and compared 30-day rates of mortality, recurrent venous thromboembolism and major bleeding between sPESI scores of 0 and 1 or greater.

Results:

Patients with a sPESI score of 0 accounted for 383 (22%) patients, and 110 (6.4%) patients died within 30 days. The cumulative 30-day incidence of mortality was lower in patients with a sPESI score of 0 than those with a sPESI score of 1 or greater (0.5% vs. 8.1%, log rank P<0.001). There was no significant difference in the cumulative 30-day incidence of recurrent venous thromboembolism between patients with a sPESI score of 0 and 1 or greater (1.3% vs. 2.8%, log rank P=0.11). The cumulative 30-day incidence of major bleeding was lower in patients with a sPESI score of 0 than those with a sPESI score of 1 or greater (1.1% vs. 4.0%, log rank P=0.005).

Conclusions:

In patients with a sPESI score of 0, the 30-day mortality, recurrent venous thromboembolism and major bleeding rates were reasonably low. The sPESI score could be useful to identify candidates for early hospital discharge or home treatment.

Malignant disease as a comorbidity in patients with severe aortic stenosis: clinical presentation, outcomes, and management

Aim

To investigate the effect of malignancy on the outcomes of patients with severe aortic stenosis (AS) and the management strategy for AS with malignancy.

Methods and results

Using data of 3815 patients with severe AS in a retrospective multicentre registry [CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry], we compared 3-year clinical outcomes among three groups based on malignancy status: with malignancy currently under treatment including best supportive care (malignancy group), with a history of malignancy without any current treatment (past history group), or without history of malignancy (no malignancy group). Patients in the malignancy group (n = 124) were more often men and had higher prevalence of low body mass index, recurrence of malignancy, anaemia, and asymptomatic status, despite comparable surgical risks and echocardiographic parameters. The malignancy group or the past history group (n = 389) had significantly higher risk for all-cause death [hazard ratio (HR) 2.49, 95% CI (95% confidence interval) 1.98-3.14; HR 1.23, 95% CI 1.04-1.46] and for malignancy-related death (HR 16.2, 95% CI 10.64-24.54; HR 3.66, 95% CI 2.43-5.52) than that of the no malignancy group (n = 3302). The excess risk for aortic valve-related death was not observed in the malignancy group (HR 0.79, 95% CI 0.48-1.29) and was lower in the past history group (HR 0.72, 95% CI 0.53-0.96). In the malignancy group, the treatment strategy (surgery: n = 16, conservative management: n = 108) was determined based on the clinical status of AS or life expectancy.

Conclusions

Malignancy had marked effect on all-cause death and malignancy-related death in patients with severe AS. History of malignancy also had a smaller but significant effect on mortality.

Discussion of “Attitude of Physi -cians Towards Automatic Alerting in Computerized Physician Order Entry Systems”

With these comments on the paper “Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems”, written by Martin Jung and co authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physi cian order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Commentaries on “Informatics and Medicine: From Molecules to Populations”

Objective: To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. “Informatics and Medicine: From Molecules to Populations”.

Method: Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper.

Results and Conclusions: The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.

Automatic DPC Code Selection from Electronic Medical Records

Objectives: We extracted index terms related to diseases recorded in hospital discharge summaries and examined the capability of the vector space model to select a suitable diagnosis with these terms.

Methods: By morphological analysis, we extracted index terms and constructed an original dictionary for the discharge summary analysis. We chose 125 different DPC (Japanese DRG system) codes for the diseases, each of which had more than 20 cases. We divided them into two groups. One group consisted of 5927 cases from 2004 fiscal year and was used to generate the document vector space according to the DPC. The other group of 3187 cases was collected to verify the automatic DPC selection by using data from 2005 fiscal year. The top 200 extracted index terms for each disease were used to calculate the weight of each disease.

Results: The DPC code obtained by the calculated similarity was compared with the original codes of patients for 125 DPCs of 3187 cases. Eighty percent of the cases matched the diagnosis of the DPC (first six digits) and 56% of the cases completely matched all 14 digits of the DPC.

Conclusions: We demonstrated that we could extract suitable terms for each disease and obtain characteristics, such as the diagnosis, from the calculated vectors. This technique can be used to measure the qualification of discharge summaries and to integrate discharge summaries among different facilities. By the text mining technique, we can characterize the contents of electronic discharge summaries and deduce diagnoses with the data.

VEGF-C and Cardiovascular Mortality in Patients Undergoing Drug-eluting Stent Implantation

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Incidence of Stroke or Systemic Embolism in Paroxysmal Versus Sustained Atrial Fibrillation

Background and Purpose—

There is controversy on the relationship of the type of atrial fibrillation (AF) to stroke. Although several studies show that patients with paroxysmal AF (PAF) have a stroke risk similar to those with persistent or permanent AF, recent studies suggest that PAF is associated with a lower rate of stroke. Limited data on stroke risk associated with PAF are evident in Asian populations.

Methods—

The Registry Study of Atrial Fibrillation Patients in Fushimi-ku (Fushimi AF Registry) is a community-based survey of patients with AF in Fushimi-ku, Kyoto, Japan. Patients were categorized into 2 types of AF: PAF or sustained (persistent or permanent) AF. We compared clinical events between PAF (n=1588) and sustained AF (n=1716).

Results—

Patients with PAF were younger, had less comorbidities, and received oral anticoagulants (OAC) less commonly. A lower risk of stroke/systemic embolism during follow-up period in the patients with PAF was consistently observed (non-OAC users: hazard ratio, 0.45; 95% confidence intervals, 0.27–0.75; P <0.01 and OAC users: hazard ratio, 0.59; 95% confidence interval, 0.35–0.93; P =0.03). The composite end point of stroke/systemic embolism/all-cause mortality was also lower in PAF, whether among OAC users (hazard ratio, 0.77; 95% confidence interval, 0.59–0.99; P =0.046) or non-OAC users (hazard ratio, 0.59; 95% confidence interval, 0.46–0.75; P <0.01). On multivariate analysis, PAF was an independent predictor of lower stroke/systemic embolism risk.

Conclusions—

In this large cohort of Japanese patients with AF, PAF was independently associated with lower incidence of stroke/systemic embolism than sustained AF. This may aid decision making for anticoagulation, especially in those patients with AF with few stroke risk factors.

Clinical Trial Registration—

URL: http://www.umin.ac.jp/ctr/index.htm . Unique identifier: UMIN000005834.

Discussion of "Attitude of physicians towards automatic alerting in computerized physician order entry systems"

With these comments on the paper "Attitude of Physicians Towards Automatic Alerting in Computerized Physician Order Entry Systems", written by Martin Jung and co-authors, with Dr. Elske Ammenwerth as senior author [1], the journal wants to stimulate a broad discussion on computerized physician order entry systems. An international group of experts have been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Data analysis and data mining: current issues in biomedical informatics

BACKGROUND

Medicine and biomedical sciences have become data-intensive fields, which, at the same time, enable the application of data-driven approaches and require sophisticated data analysis and data mining methods. Biomedical informatics provides a proper interdisciplinary context to integrate data and knowledge when processing available information, with the aim of giving effective decision-making support in clinics and translational research.

OBJECTIVES

To reflect on different perspectives related to the role of data analysis and data mining in biomedical informatics.

METHODS

On the occasion of the 50th year of Methods of Information in Medicine a symposium was organized, which reflected on opportunities, challenges and priorities of organizing, representing and analysing data, information and knowledge in biomedicine and health care. The contributions of experts with a variety of backgrounds in the area of biomedical data analysis have been collected as one outcome of this symposium, in order to provide a broad, though coherent, overview of some of the most interesting aspects of the field.

RESULTS

The paper presents sections on data accumulation and data-driven approaches in medical informatics, data and knowledge integration, statistical issues for the evaluation of data mining models, translational bioinformatics and bioinformatics aspects of genetic epidemiology.

CONCLUSIONS

Biomedical informatics represents a natural framework to properly and effectively apply data analysis and data mining methods in a decision-making context. In the future, it will be necessary to preserve the inclusive nature of the field and to foster an increasing sharing of data and methods between researchers.

Comparing a Japanese and a German hospital information system

OBJECTIVES

To examine the architectural differences and similarities of a Japanese and German hospital information system (HIS) in a case study. This cross-cultural comparison, which focuses on structural quality characteristics, offers the chance to get new insights into different HIS architectures, which possibly cannot be obtained by inner-country comparisons.

METHODS

A reference model for the domain layer of hospital information systems containing the typical enterprise functions of a hospital provides the basis of comparison for the two different hospital information systems. 3LGM(2) models, which describe the two HISs and which are based on that reference model, are used to assess several structural quality criteria. Four of these criteria are introduced in detail.

RESULTS

The two examined HISs are different in terms of the four structural quality criteria examined. Whereas the centralized architecture of the hospital information system at Chiba University Hospital causes only few functional redundancies and leads to a low implementation of communication standards, the hospital information system at the University Hospital of Leipzig, having a decentralized architecture, exhibits more functional redundancies and a higher use of communication standards.

CONCLUSIONS

Using a model-based comparison, it was possible to detect remarkable differences between the observed hospital information systems of completely different cultural areas. However, the usability of 3LGM(2) models for comparisons has to be improved in order to apply key figures and to assess or benchmark the structural quality of health information systems architectures more thoroughly.

Commentaries on "Informatics and medicine: from molecules to populations"

OBJECTIVE

To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. "Informatics and Medicine: From Molecules to Populations".

METHOD

Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper.

RESULTS AND CONCLUSIONS

The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.