Education in Methodology for Health Care – EuroMISE

In January 1993 the Joint European Project “Education in the methodology field of health care”, EuroMISE (European Education in Medical Informatics, Statistics and Epidemiology) started under the European TEMPUS program. Training and education in EuroMISE consist of three overlapping methodology branches: medical informatics, medical statistics, and epidemiology. A teaching scheme has been developed in cooperation between Charles University, Prague, and EC universities and organizations involved in the EuroMISE project. One of the main tasks of the project is to design a modularly structured EuroMISE course set, to develop teaching materials and tools in the English language, and to link the EuroMISE project with other programs and projects in this field. Running EuroMISE courses, firstly for university teachers, will have a major impact in disseminating the acquired knowledge and skills.

The Framingham Risk Function Underestimated Absolute Coronary Heart Disease Risk in Czech Men

Objectives: The aim was to validate the Framingham coronary heart disease (CHD) risk function with the formula by Wilson et al. (1998) in Czech men.

Methods: The validation was performed within the 20-year primary prevention study of atherosclerotic risk factors (STULONG) including 1417 middle-aged men from the Czech Republic (Prague). A total of 646 men examined in 1979-1988, and followed-up for ten years, were included into the validation study. The calibration and discrimination ability of the Framingham risk function in the Czech population were explored.

Results: The estimated 10-year risk of CHD by the Framingham risk function was 12.8% in 646 men, significantly higher than the observed risk (16.4 %), p = 0.013. The trend in the 10-year incidence of CHD was significantly increasing with quintiles of the estimated risk, p < 0.001. After the recalibration of the Framingham risk function, there was an insignificant difference between the estimated (18.2%) and observed (16.4%) risks of CHD, p = 0.320. The Framingham risk function classified men into those with and without CHD in the 10-year period with accuracy over 60%.

Conclusions: Unlike some validation studies from Western Europe, the Framingham risk function significantly underestimated the 10-year CHD risk in the Czech Republic. In agreement with these studies, the incidence of CHD was significantly increasing across quintiles of the estimated risk.

Electronic Health Record for Forensic Dentistry

Objectives: To identify support of structured data entry for electronic health record application in forensic dentistry.

Methods: The methods of structuring information in dentistry are described and validation of structured data entry in electronic health records for forensic dentistry is performed on several real cases with the interactive DentCross component. The connection of this component to MUDR and MUDRLite electronic health records is described.

Results: The use of the electronic health record MUDRLite and the interactive DentCross component to collect dental information required by standardized Disaster Victim Identification Form by Interpol for possible victim identification is shown.

Conclusions: The analysis of structured data entry for dentistry using the DentCross component connected to an electronic health record showed the practical ability of the DentCross component to deliver a real service to dental care and the ability to support the identification of a person in forensic dentistry.

Serum levels of matrix metalloproteinases 2 and 9 and TGFBR2 gene screening in patients with ascending aortic dilatation

Development of ascending aortic dilatation (AAD) in about 10 % of patients operated for aortic valve disease (AVD) is probably based on intrinsic pathology of the aortic wall. This may involve an abnormality in the process of extracellular matrix remodelling. The present study evaluated the serum levels of specific metalloproteinases (MMP-2 and MMP-9) and investigated the gene for transforming growth factor receptor 2 (TGFBR2) in 28 patients with AVD associated with AAD (mean age 60.6 years), in 29 patients (68.9 years) with AVD without AAD, and in 30 healthy controls (45.3 years). The serum levels of MMPs were determined by ELISA. Further, we focused on genetic screening of the TGFBR2 gene. Plasma MMP-2 concentrations were significantly higher in the groups of patients compared to the controls: median 1315.0 (mean 1265.2 ± SD 391.3) in AVD with AAD, 1240.0 (1327.8 ± 352.5) in AVD without AAD versus 902.5 (872.3 ± 166.2) ng/ml in the healthy controls, in both cases P < 0.001. The serum levels of MMP-9 were significantly higher in AVD with AAD patients [107.0 (202.3 ± 313.0)] and in AVD without AAD patients [107.0 (185.8 ± 264.3)] compared to the healthy controls [14.5 (21.2 ± 24.8) ng/ml], in both cases P < 0.001. No significant correlation was observed between plasma MMP-2 and MMP-9 and ascending aorta diameter. Genetic screening did not reveal any variation in the TGFBR2 gene in the patients. Measurement of MMP levels is a simple and relatively rapid laboratory test that could be used as a biochemical indicator when evaluated in combination with imaging techniques.

Serum levels of matrix metalloproteinases 2 and 9 in patients with acute myocardial infarction

The myocardial extracellular matrix plays an important role in maintaining the structural and functional integrity of the heart and is centrally involved in post-myocardial infarction repair processes. We analysed some genetic and proteomic aspects that could play an important role in the development of myocardial infarction. Matrix metalloproteinases are enzymes that contribute strongly to the degradation of extracellular matrix components. In this study the serological levels of MMP-2 and MMP-9 were investigated using immunological testing in 34 patients with myocardial infarction and 34 matched control subjects. The serum levels of MMPs were determined by ELISA. Changes in serum levels were characterized within 24 h and after 6 months post myocardial infarction. Significantly higher levels of MMP-2 (299.47 ± 117.61 ng/ml) and MMP-9 (93.56 ± 53.74 ng/ml) were determined in patients with myocardial infarction compared to the controls, in both cases P < 0.001. MMP-9 levels decreased significantly in the 6 months after cardiac event, whereas the levels of MMP-2 were almost equal to the post-infarction ones. While comparing the results from four patients that died of cardiovascular cause within 6 months we found significantly higher MMP-2 (435.00 ± 55.83 ng/ml, P = 0.003) and MMP-9 (166.25 ± 41.07 ng/ml, P = 0.018) values. Microarray analysis was used to determine the gene expression of selected genes for MMPs and their regulators from peripheral blood. The selected genes did not show satisfactory results that could have a potential implication for diagnostics of tissue degeneration.

[Pilot register of acute myocardial infarction--a 5-year evaluation of quality of care in non-PCI hospitals]

INTRODUCTION

The aim of this research was to describe (demographic data and cardiovascular disease risk factors) a non-selected patient population with acute myocardial infarction and to evaluate the applied diagnostic and therapeutic approaches.

PATIENTS AND METHODS

Data on 3,184 cases of acute myocardial infarction from non-PCI hospitals in Cáslav, Chrudim, Jindrichův Hradec, Kutná Hora, Písek and Znojmo were entered in a pilot register between 2003 and 2007.

RESULTS

ST elevation myocardial infarctions represented 28.5% of registered cases; primary reperfusion was indicated in 68.3% of these cases. Coronarography was indicated in 43.8% of patients in the non-ST elevation myocardial infarction subgroup. When evaluating pharmacotherapy administered during the first 24 hours following admission, a statistically significant increase in pharmacotherapy administration over the 5 years of register existence was observed (the most apparent for clopidrogel--increase from 24.6% to 63.3%). Analysis of medication recommended for use at discharge also revealed significant increase in administration of the recommended medication over the 5 years in all evaluated drug groups--the most significant, once again, for thienopyridines (increase from 34.9% to 49.6%). In-hospital mortality decreased over the 5 years from 15.2% in 2003 to 8.0% in 2007.

CONCLUSION

The 5-year evaluation of diagnostic and therapeutic approaches applied in patients with acute myocardial infarction in non-PCI hospitals confirmed improvement in care provided, specifically improved adherence to pharmacotherapy as well as interventional treatment guidelines pertinent to this patient group. Together with increased quality of care, we observed a decline in in-hospital mortality of patients with acute myocardial infarction.

Semantic interoperability in Czech healthcare environment supported by HL7 version 3

OBJECTIVES

The data interchange in the Czech healthcare environment is mostly based on national standards. This paper describes a utilization of international standards and nomenclatures for building a pilot semantic interoperability platform (SIP) that would serve to exchange information among electronic health record systems (EHR-Ss) in Czech healthcare. The work was performed by the national research project of the "Information Society" program.

METHODS

At the beginning of the project a set of requirements the SIP should meet was formulated. Several communication standards (openEHR, HL7 v3, DICOM) were analyzed and HL7 v3 was selected to exchange health records in our solution. Two systems were included in our pilot environment: WinMedicalc 2000 and ADAMEKj EHR.

RESULTS

HL7-based local information models were created to describe the information content of both systems. The concepts from our original information models were mapped to coding systems supported by HL7 (LOINC, SNOMED CT and ICD-10) and the data exchange via HL7 v3 messages was implemented and tested by querying patient administration data. As a gateway between local EHR systems and the HL7 message-based infrastructure, a configurable HL7 Broker was developed.

CONCLUSIONS

A nationwide implementation of a full-scale SIP based on HL7 v3 would include adopting and translating appropriate international coding systems and nomenclatures, and developing implementation guidelines facilitating the migration from national standards to international ones. Our pilot study showed that our approach is feasible but it would demand a huge effort to fully integrate the Czech healthcare system into the European e-health context.

Voice-supported electronic health record for temporomandibular joint disorders

OBJECTIVES

To identify support of structured data entry for an electronic health record application in temporomandibular joint disorders.

METHODS

The methods of structuring information in dentistry are described and the interactive DentCross component is introduced. A system of structured voice-supported data entry in electronic health record on several real cases in the field of dentistry is performed. The connection of this component to the MUDRLite electronic health record is described.

RESULTS

The use of DentVoice, an application which consists of the electronic health record MUDRLite and the voice-controlled interactive component DentCross, to collect dental information required by temporomandibular joint disorders is shown.

CONCLUSIONS

The DentVoice application with the DentCross component showed the practical ability of the temporomandibular joint disorder treatment support.

Overdenture - implants versus teeth - quality of life and objective therapy evaluation

An overdenture is a complete or removable partial denture that has one or more tooth roots or implants to provide a support. The study compares two types of prosthodontic treatment - overdenture supported by remained own teeth with ball attachments and that held by implants. The cohort of 35 patients (recall from 1 to 5 years) was evaluated. When subjectively and objectively assessed no significant difference between both groups was observed.

Electronic health record for forensic dentistry

OBJECTIVES

To identify support of structured data entry for electronic health record application in forensic dentistry.

METHODS

The methods of structuring information in dentistry are described and validation of structured data entry in electronic health records for forensic dentistry is performed on several real cases with the interactive DentCross component. The connection of this component to MUDR and MUDRLite electronic health records is described.

RESULTS

The use of the electronic health record MUDRLite and the interactive DentCross component to collect dental information required by standardized Disaster Victim Identification Form by Interpol for possible victim identification is shown.

CONCLUSIONS

The analysis of structured data entry for dentistry using the DentCross component connected to an electronic health record showed the practical ability of the DentCross component to deliver a real service to dental care and the ability to support the identification of a person in forensic dentistry.

Forensic dentistry--identification from the dentist's point of view

The paper deals with an identification of missing persons based on a dental documentation. The procedure of the identification is presented in two case reports with a new possibility of electronic imaging called Dental Cross in comparison with classical dental documentation, which is officially used for identification of the missing persons by Interpol.

[Prolactin response to stress in patients with systemic lupus erythematodes (SLE), rheumatoid arthritis (RA) and in healthy controls]

Prolactin is a one of the stress hormones, like the growth hormone, ACTH, cortisol and catecholamins. Among its wide range of functions is the important role of controlling the immune response which is, unlike in the case of cortisol, of stimulatory nature. For this activity, it is monitored as a factor influencing the progress and course of autoimmune diseases. The authors of the paper monitored prolactin response to stress in a normal stress situation, i.e. blood collection. A significant difference was detected between the levels of prolactin in 3 successive blood collections in 30 minute intervals (P < 0.001). Prolactin responded by a prompt increase in the serum level, followed by a relatively fast linear decrease. There was no difference in the response between the SLE and RA patient groups and the healthy population. Therefore we conclude that this is a normal reaction of the organism because acute response to stress in patients with autoimmune diseases is the same as in healthy persons.

The Framingham risk function underestimated absolute coronary heart disease risk in Czech men

OBJECTIVES

The aim was to validate the Framingham coronary heart disease (CHD) risk function with the formula by Wilson et al. (1998) in Czech men.

METHODS

The validation was performed within the 20-year primary prevention study of atherosclerotic risk factors (STULONG) including 1417 middle-aged men from the Czech Republic (Prague). A total of 646 men examined in 1979-1988, and followed-up for ten years, were included into the validation study. The calibration and discrimination ability of the Framingham risk function in the Czech population were explored.

RESULTS

The estimated 10-year risk of CHD by the Framingham risk function was 12.8% in 646 men, significantly higher than the observed risk (16.4 %), p = 0.013. The trend in the 10-year incidence of CHD was significantly increasing with quintiles of the estimated risk, p < 0.001. After the recalibration of the Framingham risk function, there was an insignificant difference between the estimated (18.2%) and observed (16.4%) risks of CHD, p = 0.320. The Framingham risk function classified men into those with and without CHD in the 10-year period with accuracy over 60%.

CONCLUSIONS

Unlike some validation studies from Western Europe, the Framingham risk function significantly underestimated the 10-year CHD risk in the Czech Republic. In agreement with these studies, the incidence of CHD was significantly increasing across quintiles of the estimated risk.

Comparison of FK 506, mycophenolate mofetil, and aminoguanidine effects on delay of corneal allograft rejection in an experimental model of low-risk and high-risk keratoplasty

The purpose of our study was to compare the effectiveness of immunosuppressive drugs on the prevention of allograft rejection in a murine model of low-risk and high-risk keratoplasty. The therapy included FK 506 (tacrolimus; 0.2 mg/kg), mycophenolate mofetil (30 mg/kg), aminoguanidine (0.1 g/kg), and combination of FK506 + mycophenolate mofetil or FK506 + aminoguanidine. The results obtained from the Gray's survival model stratified according to the type of subjects suggest that a major rejection risk reduction was achieved using FK506; good results also were obtained for mycophenolate mofetil. Although the point estimates of both the survival and relative risk of rejection suggest a deferred effect of the combination FK506 + mycophenolate mofetil, this finding did not prove statistically significant.

[Intrapartal fetal monitoring, sensitivity and specificity of methods]

OBJECTIVE

To evaluated sensitivity and specificity of presently used methods for intrapartal monitoring (CTG, FpO2 a STAN S-21) and their mutual comparison.

TYPE OF STUDY

A prospective study.

SETTING

Gynecological-Obstetrical Clinic, 1st Medical Faculty, Charles University and general Teaching Hospital, Prague.

METHOD

In 114 pregnant women with high-risk or pathological course of pregnancy the authors evaluated the capability of individual methods to predict intrapartal hypoxia, determined on the basis of postnatal evaluation of parameters observed (Apgar score in 1st minute, pH from umbilical artery, lactate levels in fetal blood, base excess (BE) and postpartum condition of fetus evaluated by a neonatologist). Each method was categorized according to its importance. The quality of individual methods was evaluated by means of their sensitivity and specificity as well as by the area under ROC (Receiver Operating Characteristic), i.e. AUC (Area under Curve). A similar or different prediction of the condition of the newborn by these individual methods was evaluated by the McNamara test of symmetry. In 50 deliveries performed by Cesarean section and 24 forceps deliveries the authors evaluated postnatal pH from umbilical artery and evaluation by Chi-square test. The women in childbed were infused with a tocolytic drug (hexoprenalin) before Cesarean section. All tests were performed at 5% level of significance.

RESULTS

Low level of Apgar score in the 1st minute and less) always indicated CTG, but also a large proportion of normal newborns. STAN, in contrast, well indicates all newborns with a normal point evaluation. The best balanced evaluation of the newborns is provided by FpO2 and there was a significant difference between CTG and FpO2. In evaluating pH from the umbilical artery (pH < 7.20), TCG proved to be most sensitive again but displayed low specificity. STAN was the best predictor of newborns with normal pH. In evaluating high levels of lactate (> 3.7mmol/L) and BE (> -10) and related demonstration of metabolic acidosis STAN proved to be the best predictor. The condition of the newborn evaluated by a neonatologist immediately after birth (medium or heavy depression) was best predicted by FpO2. In deliveries performed by Cesarean section and after the administration of tocolysis the postnatal pH was higher then in forceps deliveries without acute tocolysis. The occurrence of emergencies in the course of a pathological delivery in individual methods is as follows: CTG, FpO2 and STAN.

CONCLUSION

Even though CTG displays a very low specificity, this method should not be rejected, since it draws attention of the obstetrician very early to the possibility of developing hypoxia. FpO2 or STAN gives more precision to the situation and demarcates a correct moment for ending the delivery for the indication of fetus hypoxia intra partum. STAN is the best predictor for conditions of developing metabolic acidosis, evaluated postnatally by the level of lactate and BE in fetal blood.

[Primary prevention of ischemic heart disease in middle-aged men living in Prague: results of twenty-year research]

INTRODUCTION

Ischemic Heart Disease (IHD) represents the most frequent cause of mortality and morbidity in the Czech Republic. The aim of this study is to analyze long-term mortality of cardiovascular disease (CVD), identify its predictors and verify the validity of Framingham risk function for Czech patients.

DESIGN AND METHODS

The twenty-year study (STULONG) of primary prevention of risk factors of atherosclerosis in 1419 men aged 38 to 53 years living in Prague was started in 1975.

RESULTS

CVD mortality analysis showed a higher risk of death for heavy smokers vs. non-smokers or light smokers (p < 0.0001), hypertensive patients vs. patients with normal blood pressure (p < 0.0001), men with hypercholesterolemia vs. men with normal cholesterol level (p = 0.0432), and a lower risk for university graduates vs. men with elementary education (p = 0.0006). Between 1980 and 1984, age-specific CVD mortality rates of men from STULONG study were higher (p = 0.0132) than national CVD mortality rates; between 1985 and 1994, they were insignificantly lower. Framingham risk function underestimated absolute ten-year risk of IHD in all risk quintiles (p < 0.0001) with discrimination of 63%.

CONCLUSION

CVD mortality observed within STULONG study was significantly affected by known risk factors (hypertension, smoking, hypercholesterolemia, lower education); Framingham risk function underestimated absolute ten-year risk of IHD.

On Genetic Information, Diversity and Distance

Objectives: General information-theoretic concepts such as f-divergence, f-information and f-entropy are applied to the genetic models where genes are characterized by randomly distributed alleles. The paper thus presents an information-theoretic background for measuring genetic distances between populations, genetic information in various observations on individuals about their alleles and, finally, genetic diversities in various populations.

Methods: Genetic distances were derived as divergences between frequencies of alleles representing a gene in two different populations. Genetic information was derived as a measure of statistical association between the observations taken on individuals and the alleles of these individuals. Genetic diversities were derived from divergences and information.

Results: The concept of genetic f-information introduced in the paper seems to be new. We show that the measures of genetic distance and diversity used in the previous literature are special cases of the genetic f-divergence and f-diversity introduced in the paper and illustrated by examples. We also display intimate connections between the genetic f-information and the genetic f-divergence on one side and genetic f-diversity on the other side. The examples at the same time also illustrate practical computations and applications of the important concepts of quantitative genetics introduced in the paper.

Conclusions: We discussed a general class of f-divergence measures that are suitable measures of genetic distance between populations characterized by concrete frequencies of alleles. We have shown that a wide class of genetic information, called f-information, can be obtained from f-divergences and that a wide class of measures of genetic diversity, called f-diversities, can be obtained from the f-divergences and f-information.

On genetic information, diversity and distance

OBJECTIVES

General information-theoretic concepts such as f-divergence, f-information and f-entropy are applied to the genetic models where genes are characterized by randomly distributed alleles. The paper thus presents an information-theoretic background for measuring genetic distances between populations, genetic information in various observations on individuals about their alleles and, finally, genetic diversities in various populations.

METHODS

Genetic distances were derived as divergences between frequencies of alleles representing a gene in two different populations. Genetic information was derived as a measure of statistical association between the observations taken on individuals and the alleles of these individuals. Genetic diversities were derived from divergences and information.

RESULTS

The concept of genetic f-information introduced in the paper seems to be new. We show that the measures of genetic distance and diversity used in the previous literature are special cases of the genetic f-divergence and f-diversity introduced in the paper and illustrated by examples. We also display intimate connections between the genetic f-information and the genetic f-divergence on one side and genetic f-diversity on the other side. The examples at the same time also illustrate practical computations and applications of the important concepts of quantitative genetics introduced in the paper.

CONCLUSIONS

We discussed a general class of f- divergence measures that are suitable measures of genetic distance between populations characterized by concrete frequencies of alleles. We have shown that a wide class of genetic information, called f-information, can be obtained from f-divergences and that a wide class of measures of genetic diversity, called f-diversities, can be obtained from the f-divergences and f-information.

The New Features of the ExaMe Evaluation System and Reliability of Its Fixed Tests

Objectives: The ExaMe system for the evaluation of targeted knowledge has been in development since 1998. The new features of the ExaMe system are introduced in this paper. Especially, the new three-layer architecture is described.

Besides the system itself, the properties of fixed testsin the ExaMe system are studied. In special detail, the reliabilityof the fixed tests is discussed. The theory background is explained and some limitations of the reliability are pointed out.

Methods for Estimation of the Reliability: Three characteristics used for estimation of reliability of educational tests are discussed: Cronbach’s alpha, standardized item alphaand split half coefficient. The relation between these characteristics and reliability and between characteristics themselves is investigated. In more detail, the properties of Cronbach’s alpha, the characteristics mostly used for the estimation of reliability, are discussed. A confidence interval is introduced for the characteristics.

Results and Conclusions: Since 2000, the serviceability of the ExaMe evaluation system as the supporting evaluation tool has been repeatedly shown at the courses of Ph.D. studies in biomedical informatics at Charles University in Prague. The ExaMe system also opens new possibilities for self-evaluation and distance learning, especially when connected with electronic books on the Internet.

The estimation of reliability of tests contains some limitations. Keeping them in mind, we can still get some information about the quality of certain educational tests. Therefore, the estimation of reliability of the fixed tests is implemented in the ExaMe system.

The new features of the ExaMe evaluation system and reliability of its fixed tests

OBJECTIVES

The ExaMe system for the evaluation of targeted knowledge has been in development since 1998. The new features of the ExaMe system are introduced in this paper. Especially, the new three-layer architecture is described. Besides the system itself, the properties of fixed tests in the ExaMe system are studied. In special detail, the reliability of the fixed tests is discussed. The theory background is explained and some limitations of the reliability are pointed out.

METHODS FOR ESTIMATION OF THE RELIABILITY

Three characteristics used for estimation of reliability of educational tests are discussed: Cronbach's alpha, standardized item alpha and split half coefficient. The relation between these characteristics and reliability and between characteristics themselves is investigated. In more detail, the properties of Cronbach's alpha, the characteristics mostly used for the estimation of reliability, are discussed. A confidence interval is introduced for the characteristics.

RESULTS AND CONCLUSIONS

Since 2000, the serviceability of the ExaMe evaluation system as the supporting evaluation tool has been repeatedly shown at the courses of Ph.D. studies in biomedical informatics at Charles University in Prague. The ExaMe system also opens new possibilities for self-evaluation and distance learning, especially when connected with electronic books on the Internet. The estimation of reliability of tests contains some limitations. Keeping them in mind, we can still get some information about the quality of certain educational tests. Therefore, the estimation of reliability of the fixed tests is implemented in the ExaMe system.

Primary prevention of coronary artery disease among middle aged men in Prague: Twenty-year follow-up results

BACKGROUND

Coronary artery disease (CAD) represents the most common cause of morbidity and mortality in the Czech Republic. The aim of this study is to analyze long-term cardiovascular diseases (CVD) mortality, identify predictors of outcome and to validate the Framingham risk function in men from the Czech Republic.

DESIGN AND METHODS

A 20-year primary prevention study of atherosclerosis risk factors in 1417 men from Prague aged 38-53 years was launched in 1975 (STULONG).

RESULTS

When analyzing CVD mortality, heavy smokers had hazard higher than non-smokers and light smokers (p < 0.0001); hypertensives higher than normotensives (p < 0.0001); men with hypercholesterolemia higher than those with normal cholesterol (p = 0.0432), and university-educated men lower than elementary-educated men (p = 0.0006). In 1980-1984, the age specific mortality from CVD in men from STULONG was higher (p = 0.0132) than in the Czech Republic, in 1985-1994 insignificantly lower. The Framingham risk function underestimated the absolute 10-year risk of CAD across the quintile of the risk (p < 0.0001), with 63% discrimination.

CONCLUSION

In STULONG, the mortality from CVD was significantly associated with known risk factors (hypertension, smoking, hypercholesterolemia, education); the Framingham risk function underestimated the absolute 10-year risk of CAD.

Triangulation applied to Jan H. van Bemmel

OBJECTIVE

To describe the person of Jan H. van Bemmel from different points of view.

METHOD

Triangulation.

RESULTS AND CONCLUSIONS

Jan H. van Bemmel successfully contributed to research and education in medical informatics. He inspired a lot of people in The Netherlands and internationally.

[Comparison of organochlorine pesticide levels in blood and follicular fluid of infertile women]

OBJECTIVE

The aim of this study was to detect DDT and its metabolites, lindane and its conformers (alfa, beta, gama and delta conformers of hexachlorocyklohexane - HCH) and hexacyclobenzene (HCB) in blood and follicular fluid of infertile women undergoing IVF+ET program. In the case if their detection, to confirm their cumulation in follicular fluid.

DESIGN

Pilot study.

SETTING

Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, AXYS Varilab s.r.o., Vrané nad Vltavou, Institute of Hygiene and Epidemiology, 1st Faculty of Medicine Charles University and General Faculty Hospital, Prague, Euromise Centrum, Charles University and Academy of Arts, Prague, Czech republic.

METHODS

We detected the level of DDT, DDE, DDD, lindane and its conformers (alfa, beta, gama and delta conformers of hexachlorocyklohexane - HCH) and hexacyclobenzene (HCB) in blood and folicular fluid of 30 infertile women undergoing IVF + ET program. We recieved the follicular fluid by transvaginal punction of follicular fluid under ultrasonography control. The venous blood was taken before begining of anestesia. The follicular fluid and blood were frozen and transported to the laboratory. There the samples were examinated by the methods of gass chromatography and mass spectrometry.

RESULTS

We confirmed the possibility of detection of DDT, DDE, DDD, lindane and its conformers (alfa, beta, gama and delta conformers of hexachlorocyclohexane - HCH) and hexacyclobenzene (HCB) in blood and follicular fluid of infertile women. The differences in concentrations in blood and follicular fluid were statistically analysed. We confirmed the cumulation of DDT, DDE, DDD, lindane and its conformers (alfa, beta, gama and delta conformers of hexachlorocyclohexane - HCH) and hexacyclobenzene (HCB) in follicular fluid of infertile women. The levels of these compounds in blood differed from 2.8 to 6399.3 ng/g of fat, in follicular fluid from 1.4 to 4 099.8 ng/g of fat.

CONCLUSION

It is possible to detect DDT, DDE, DDD, lindane and its conformers (alfa, beta, gama and delta conformers of hexachlorocyclohexane - HCH) and hexacyclobenzene (HCB) in blood and follicular fluid of infertile women. The cumulation of these xenobiotics in follicular fluid was found.

[Relationship between the levels of toxic polychlorinated biphenyls in blood and follicular fluid of sterile women]

OBJECTIVE

The aim of this study was to confirm the possibility of detection of toxic polychlorinated biphenyls in blood and follicular fluid of infertile women undergoing IVF+ET program and determine the levels of some congeners. To confirm their cumulation in follicular fluid.

DESIGN

Pilot study.

SETTING

Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, AXYS Varilab s.r.o., Vrané nad Vltavou, Institute of Hygieny and Epidemiology, 1st Faculty of Medicine Charles University and General Faculty Hospital, Prague, Euromise Centrum, Charles University, Prague.

METHODS

We detected the level of polychlorinated biphenyls in blood and follicular fluid of infertile women undergoing IVF+ET program. We recieved the follicular fluid by transvaginal punction of follicles under ultrasonography control. The blood was taken before begining of anestezia. The follicular fluid and blood were frozen and transported to the laboratory. The samples were examined there by methods of gas chromatography and mass spectrometry. We were able to find all PCBs with 3-7 atoms of chlorine.

RESULTS

We confirmed the possibility of detection of polychlorinated biphenyls (PCBs) in blood and follicular fluid of infertile women. We examineted the levels of PCB 77, 81, 105, 114, 118+123, 126, 156, 157, 167, 169, 189. The levels of PCBs were in ng/gram of fat. The levels of polychlorinated biphenyls differed from 0 to 400 ng/g of fat. Statistical analysis was made by t test a Wilcox test. All PCBs are cumulated in follicular fluid, except of PCB 126.

CONCLUSION

The possibility of detection of PCBs in blood and follicular fluid of infertile women undergoing IVF+ET program was confirmed. The cumulation of these xenobiotics in follicular fluid was found. In the future we will analyse the relationship between the presence of these xenobiotics and achieving succesful pregnancy.

[Differences in the polychlorinated biphenyl levels in follicular fluid in individual types of sterility]

OBJECTIVE

To find the differences of polychlorinated biphenyls (PCBs) levels in follicular fluid in different indications to treatment with IVF + ET program.

DESIGN

Pilot study.

SETTING

Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University and General Faculty Hospital, Prague, AXYS Varilab, s.r.o., Vrané nad Vltavou, Prague, Euromise Centrum, Charles University and Academy of Art, Prague.

METHODS

We examinated 100 infertile women undergoing IVF + ET program in our pilot study. After ovarian pick-up, frozen follicular fluid were transported to the laboratory. We detected the levels of polychlorinated biphenyls in follicular fluid of infertile women. The levels were compared according to the different indications of treatment. The control group consist of patients with male factor of sterility.

RESULTS

We confirmed the higher levels of PCB 114, 153, 156, 157, 180 and 189 in indication endometriosis compared with the others and with control group. The levels of PCBs were in ng/gram of fat.

CONCLUSION

It has become apparent that higher levels of PCB 114, 153, 156, 157, 180 and 189 in endometriosis patients may be one of many factors participating in the origin of the disease.

Effects of inhibition of urokinase-type plasminogen activator (u-PA) by amiloride in the cornea and tear fluid of eyes irradiated with UVB

The purpose of the present study was to test our hypothesis that amiloride, a specific u-PA inhibitor, effectively decreases u-PA activity in cornea as well as in tear fluid and favourably affects corneal healing. Therefore, comparative histochemical and biochemical studies of u-PA and the effects of amiloride were performed on rabbit corneas and tear fluid using the sensitive fluorogenic substrate Z-Gly-Gly-Arg-7-amino-4-trifluoromethylcoumarin. Rabbit eyes were repeatedly irradiated with UVB for 9 days and during the irradiation topically treated with amiloride (1 mg/ml saline) or placebo (saline) (dropwise, 5 times daily). Results show that in placebo-treated eyes, UVB evoked the appearance of u-PA activity in cornea and tear fluid in early stages of irradiation, and u-PA levels increased during irradiation. Corneal epithelium was gradually lost and remnants of the epithelium as well as keratocytes in the upper part of corneal stroma showed high u-PA activity. Finally, corneas lost their epithelium completely. In corneal stroma, numerous u-PA-containing inflammatory cells were present. Corneas were vascularized. When amiloride was dropped on the eye surface on the first day of irradiation and subsequently daily until the end of the experiment, u-PA activity in both cornea and tear fluid was strongly inhibited. Corneas were covered with a continuous epithelium until the end of the experiment. The number of inflammatory cells was significantly decreased. Corneal vascularization was reduced by 50%. In conclusion, early application of amiloride inhibited u-PA activity in UVB-irradiated corneas as well as in tear fluid and diminished the development of corneal pathology.

Genetic determinants of folate status in Central Bohemia

Although several genetic factors have been implicated as determinants of blood folate concentration in various populations, their effect on folate status in the Czech population has not yet been examined. We explored whether blood folate concentrations in healthy Czech population are associated with polymorphisms in 5,10-methylenetetrahydrofolate reductase (MTHFR), folate hydrolase 1 (FOLH1), reduced folate carrier (RFC), and folate receptor (FOLR1) genes. In a cross-sectional study of 591 control subjects we determined genotypes by PCR-RFLP or ARMS-PCR methods, and plasma and erythrocyte folates by MEIA. The effect of different genotypes on folate status was examined by non-parametric tests and by regression analysis. The prevalence of the MTHFR 677C>T, MTHFR 1298A>C, FOLH1 1561C>T, RFC 80G>A and FOLR1 480G>C variant alleles was 0.34, 0.33, 0.05, 0.44 and 0.00, respectively. Only the MTHFR 677C>T variant was significantly associated with plasma folate concentrations (median 14.7, 14.0 and 12.2 nmol/l for the CC, CT and TT genotypes, respectively). Our study showed that among the five studied allelic variants, only the 677C>T polymorphism in the MTHFR gene is a significant genetic determinant of plasma folate concentrations in Czech population.

Genetic determinants of folate status in Central Bohemia

Although several genetic factors have been implicated as determinants of blood folate concentration in various populations, their effect on folate status in the Czech population has not yet been examined. We explored whether blood folate concentrations in healthy Czech population are associated with polymorphisms in 5,10-methylenetetrahydrofolate reductase (MTHFR), folate hydrolase 1 (FOLH1), reduced folate carrier (RFC), and folate receptor (FOLR1) genes. In a cross-sectional study of 591 control subjects we determined genotypes by PCR-RFLP or ARMS-PCR methods, and plasma and erythrocyte folates by MEIA. The effect of different genotypes on folate status was examined by non-parametric tests and by regression analysis. The prevalence of the MTHFR 677C>T, MTHFR 1298A>C, FOLH1 1561C>T, RFC 80G>A and FOLR1 480G>C variant alleles was 0.34, 0.33, 0.05, 0.44 and 0.00, respectively. Only the MTHFR 677C>T variant was significantly associated with plasma folate concentrations (median 14.7, 14.0 and 12.2 nmol/l for the CC, CT and TT genotypes, respectively). Our study showed that among the five studied allelic variants, only the 677C>T polymorphism in the MTHFR gene is a significant genetic determinant of plasma folate concentrations in Czech population.

[Analysis of present diagnostic methods of intrapartum fetal hypoxia]

OBJECTIVE

To evaluate specificity of present diagnostic methods of intrapartal fetal hypoxia (cardiotocography--CTG, fetal pulse oxymetry--FpO2, ST-ECG analysis).

DESIGN

A prospective study.

SETTING

Gynecology-Obstetrics Clinic, 1st Medical Faculty and General Faculty Hospital in Prague.

METHODS

The results of synchronic fetus monitoring by means of CTG, FpO2 and STAN-ST 21 were followed in 53 mothers with a risk and pathological delivering of birth in the period of April 2003 to March 2004. The study investigated, which of the methods provided the best prediction of the intrapartal fetal hypoxia. The statistical evaluation (p-mark test and Mc Namara test) was based on the assessment of correct or incorrect prediction of the Apgar score values in the first minute after birth, pH in umbilical artery and the lactate level. We also investigated results of three methods during postpartum depression, turbid or mushy amniotic fluid and the way the individual methods were made useful in indication for ending the delivery.

RESULTS

In comparison with CTG there was a statistically significantly higher specificity in FpO2 and STAN in the evaluation of Apgar score in the newborn in the first minute after birth, FpO2 (p=0.007) and STAN-ST (p<0.001), in the determination of pH (a) from umbilical blood FpO2 (p=0.029) and STAN (p=0.001) and the occurrence of postpartum depression of the newborn in minute 30-60 after birth FpO2 (p=0.019) and STAN (p=0.0005). The changes in lactate level in umbilical blood were better predicated by STAN (p=0.001). FpO2 evaluated the changes in the same way as CTG. The threatening hypoxia in strongly turbid or even mushy amniotic fluid was correctly evaluated by STAN only (p=0.002). The FpO2 evaluation was not statistically significant. There was not any statistically significant difference in the indication of operation for ending the delivery among the individual methods.

CONCLUSIONS

The results univocally demonstrated that the used of other method for diagnosis on intrapartal fetus hypoxia--Fetal pulse oxymetry and ST--analysis of ECG of the fetus give more precision to the diagnosis. The introduction of these methods requires a correct interpretation and the effort of the obstetrician to use these methods in clinical practice.

New approaches to health promotion and informatics education using Internet in the Czech Republic

The paper describes nowadays information technology skills in the Czech Republic. It focuses on informatics education using Internet, ECDL concept and the links between computer literacy among health care professionals and quality of health care. Everyone understands that the main source of wealth of any nation is information management and the efficient transformation of information into knowledge. There appear completely new decisive factors for the economics of the near future based on circulation and exchange information. It is clear that modern health care cannot be built without information and communication technologies. We discuss several approaches how to contribute to some topics of information society in health care, namely the role of electronic health record, structured information, extraction of information from free medical texts and sharing knowledge stored in medical guidelines.

Synergy between medical informatics and bioinformatics: facilitating genomic medicine for future health care

In this paper, we review the results of BIOINFOMED, a study funded by the European Commission (EC) with the purpose to analyse the different issues and challenges in the area where Medical Informatics and Bioinformatics meet. Traditionally, Medical Informatics has been focused on the intersection between computer science and clinical medicine, whereas Bioinformatics have been predominantly centered on the intersection between computer science and biological research. Although researchers from both areas have occasionally collaborated, their training, objectives and interests have been quite different. The results of the Human Genome and related projects have attracted the interest of many professionals, and introduced new challenges that will transform biomedical research and health care. A characteristic of the 'post genomic' era will be to correlate essential genotypic information with expressed phenotypic information. In this context, Biomedical Informatics (BMI) has emerged to describe the technology that brings both disciplines (BI and MI) together to support genomic medicine. In recognition of the dynamic nature of BMI, institutions such as the EC have launched several initiatives in support of a research agenda, including the BIOINFOMED study.

[Gastrointestinal tract cancer and diabetes mellitus]

Risk of development of some gastrointestinal tract cancers (colorectal cancer, pancreas cancer and liver cancer) is higher in type II diabetics. Another important risk factor is obesity (for gall bladder cancer in women and in men also for stomach and esophageal cancer). Pathogenetic factors have been explored especially in colorectal cancer (diet, hyperinsulinaemia, metabolic receptors activation, absence of physical activity). Our Czech study also proved up to 4 times increased risk of colorectal cancer in diabetics and, in accordance with literature, probable influence of persistent diabetes on tumour development. Type II diabetes mellitus should be considered as a risk factor especially for colorectal cancer, liver cancer, and pancreas cancer. In type I diabetics no risk of gastrointestinal tract cancers was proved.

Development of third molar in the Czech population

The third molar development was studied on the basis of 1700 panoramic radiographs analysis of randomly selected individuals in the age ranging between 5-21 years inclusive. Each age group consisted of 100 probands--50 boys and 50 girls. The characteristics of the third molar development were following: time of dental follicle formation--dynamics of development--the most frequent stages of third molar development in individual age groups-- intraindividual differences and symmetry of development--incidence of 1-4 third molars agenesis--relation between the third molar development and the dental age--differences in the third molar development between individuals with all four third molars present and individuals with 1-3 third molars agenesis--ntersexual differences. On the basis of our analysis of seven stages of development, differences of this process between males and females and the changes in dynamics of development characterizing upper and lower jaw were described. The incidence of the third molar agenesis was statistically significant, being more frequent in boys (24.2%) than in girls (17.6%). The study showed, that when the third molar is not present at the age of thirteen, it could be taken in the Czech population as agenesis. Correlation between developmental stage of third molars and dental age was ascertained. With the exception of the agenesis, no other statistically significant intersexual differences were found.

Agenesis of third molars in young Czech population

The aim of this study is to evaluate the incidence of third molars agenesis in the Czech population. One thousand patient's panoramic radiographs of the pedostomatological department of Second Stomatological Clinic of The First Faculty of Medicine, Charles University, has been analyzed. The age of probands was ranging between 12 to 21 years inclusive. Patients were divided into 10 groups according to age. In each age group were 100 individuals - 50 boys and 50 girls. Agenesis of 1-4 third molars was present in 22.5% (25.6% in boys and 19.4% in girls). Intersexual difference is significant. Further, the incidence of third molars agenesis in individual dentition quadrants, upper and lower jaw and right and left side of dentition was examined. Neither in boys nor in girls were detected significant differences in these values. Agenesis of just one, any third molar occurs in 10.9% (12.0% in boys and 9.9% in girls). For one individual it is mean 1.9 congenitally missing third molars in boys and 2.0 congenitally missing third molars in girls. These intersexual differences are not significant. In boys, the most frequent agenesis was of one, next of two, then of three and at last of four third molars. In girls, agenesis of two was on the first place, then that of one and lastly and equally of three and of four third molars. The results were compared with literature data.

Analysis of the reasons for DMARD therapy discontinuation in patients with rheumatoid arthritis in the Czech and Slovak republics

The aim of the study was to evaluate the efficacy and safety of disease-modifying drugs (DMARDs) in everyday clinical practice in Central European States (the Czech and Slovak republics). This was a retrospective, multicentre study. With the help of a special questionnaire, the medical files of 760 patients in 15 centres were analysed looking for reasons for DMARD discontinuation (e.g. insufficient efficacy, toxicity). The secondary endpoints were duration of therapy with individual DMARDs and the influence of other factors (demographic, disease specific, concomitant therapy) on duration of therapy. In 47.1 % of patients therapy was interrupted because of lack of efficacy, in 43.2 % because of adverse events, and in 9 % for undefined reasons. Toxic reactions leading to withdrawal were most common with gold (62.6 %) and methotrexate (62.5 %). Because of insufficient effect, treatment was most frequently interrupted with antimalarials (62.3 %) and penicillamine (53.2 %), but in only 22% treated with methotrexate. The mean duration of one treatment episode with DMARDs was 28.1 +/- 48.9 months. Surprisingly, it was longest for cyclophosphamide (53.5 + 55.1 months) and shortest for cyclosporin (7.0 +/- 6.7 months). The mean duration of treatment with methotrexate was only 14.9; +/- 16.2 months. The mean duration of treatment with one DMARD was statistically longer in patients with positive rheumatoid factor, extra-articular disease and age lower than 50 years. There was no impact of sex, concomitant steroid treatment and high or low sedimentation rate on treatment duration. Considerable differences in everyday clinical practice with DMARDs between Central European states and published data from the US and western Europe have been found. More education about modern strategies in the treatment of RA is probably necessary for practising rheumatologists.

[Effect of salpingectomy on the results of IVF in women with tubal sterility--prospective study]

OBJECTIVE

To compare the IVF results after salpingectomy of hydrosalpinges visible on ultrasound with IVF results in women with tubal infertility but without hydrosalpinx.

DESIGN

Prospective study.

SETTING

Sanatorium Pronatal, Na Dlouhé mezi 4/12, 147 00, Praha 4.

METHODS

101 women with tubal factor infertility were evaluated. In a prospective study we compared the results of first IVF cycle after salpingectomy of hydrosalpinges visible on ultrasound performed in 51 women (study group) with IVF results of 50 women with tubal infertility (confirmed by HSG and laparoscopy) but without hydrosalpinges and without salpingectomy.

RESULTS

The maternal age in both groups (32.4 +/- 3.9 in salpingectomy group and 33.0 +/- 4.1 in control group), maximum estradiol levels (1392.6 +/- 675.8 pg/ml in salpingectomy group vers. 1624.7 +/- 909.7 pg/ml in control group), number of oocytes (11.3 +/- 5.8 after salpingectomy vers. 11.0 +/- 6.1 in controls), number of embryos generated (7.1 +/- 4.6 vers. 7.9 +/- 4.7) and number of embryos transferred were not statistically different. In their first IVF cycle after salpingectomy has been performed 30 women out of 51 became clinically pregnant (58.8%), while in control group a clinical pregnancy could be verified in 16 women (32.0%). Implantation rate in women after salpingectomy was 28.2% vers. 12.3% in control group. Both implantation rate and pregnancy rate were statistically different at 5% level of significance.

CONCLUSION

After salpingectomy of hydrosalpinges visible on ultrasound the implantation rate and clinical pregnancy rate are significantly better when compared to IVF patients with tubal infertility without the presence of hydrosalpinges and without salpingectomy. Salpingectomy should be offered to all patients with hydrosalpinges visible on ultrasound. Moreover, this radical approach should be considered even in women with highly damaged tubes but without the presence of hydrosalpinges.

Evaluation of medical knowledge using electronic textbooks and ExaMe program on Internet

In the paper we describe the function of the ExaMe program that serves for evaluation of students knowledge using Internet. Evaluation is based on the knowledge base of a given course. Two types of evaluation tests are described. The fixed test is appropriate for examination of students by the teacher in computer classroom connected to Internet. By this test the evaluation is done in the limited time period and all students are tested with the same evaluation test. The automatic test is appropriate for self-evaluation and self-study by students on remote places. The student can ask the ExaMe program for the test of different difficulty levels and state the number of questions required. Finally the first experience with the ExaMe program in practice is given. The application of the ExaMe program is shown in connection with IT EDUCTRA electronic products and electronic textbook on biomedical statistics.

Czech national data standards implementations in ORCA electronic patient record in cardiology

In the paper we describe the situation concerning Czech data standards and requirements on health care providers. Further we compare the nowadays possibilities of the multimedia electronic patient record ORCA and its extension to fulfill Czech data standards and requirements.

[Perinatal outcome of twin pregnancies after fertilization in vitro and after spontaneous conception]

OBJECTIVE

To compare the obstetric outcome of twin pregnancies after IVF with spontaneously conceived twins and thus determine whether IVF twins require greater care.

TYPE OF STUDY

A retrospective study.

SETTING

The Department of Obstetrics and Gynaecology, 1st Faculty of Medicine of Charles University, Prague.

METHODS

Statistical evaluation of obstetric outcome between the group of 46 twin pregnancies after IVF and 85 spontaneously conceived twins. We evaluated the following parameters: signs of abortion and premature delivery, bleeding in pregnancy, premature rupture of membranes, performed cerclage, incidence of praeclampsia, gestational diabetes mellitus and hepatopathy of the mother. Pathological ultrasound findings were also evaluated--disturbances in foetal growth and the amount of amniotic fluid. In these parameters we also evaluated the time of the first signs of their development. Further, we evaluated the type of delivery, the gestational age at delivery, birth weight, birth weight discordance and perinatal mortality.

RESULTS

We found statistically significant differences in the method of delivery--more cesarean sections in the IVF group (71.7%) than in spontaneous ones (44.7%). Another difference was the gestational age at which cerclage were performed--earlier in the IVF group (average 22.8 weeks) than in spontaneous ones (average 25.7 weeks). In the other evaluated parameters we did not find any statistically significant differences between the two groups.

CONCLUSION

In our retrospective analysis of twin pregnancies, deliveries and neonatal outcome, except for the method of delivery and time of performing cerclage, we did not find any important significant differences between the IVF and spontaneously conceived twins. However, it is necessary to remember the generally worse obstetric outcome of twin compared to singleton pregnancies.

[Does reduction in multifetal pregnancy increase the risk of poor outcome in twin pregnancy?]

OBJECTIVE

To compare perinatal results for multi-foetal pregnancies where the reduction was performed with pregnancies where the reduction was not performed.

SETTING

Sanatorium Pronatal, Na Dlouhé mezi 4/12, 147 00, Praha 4--Hodkovicky.

METHODS

We have analyzed results of pregnancies, after delivery, for women with twin pregnancy which originated in our sanatorium, as a result of treatment with assisted reproduction methods, in the period of time from January 1st 1996 to December 31st 1998. In the group being monitored there were 122 twin pregnancies originated as a result of reduction of triple and more-foetal pregnancies. We evaluated the percentage of miscarriages, length of pregnancies, weight of the newborns and the manner of termination of the delivery. These results were compared with our control group consisting of 180 cases of twin pregnancies which were not a result of reduction.

RESULTS

Analysis was performed for those mothers only where complete data were available. At a 5% level of statistical significance, it was not proved that both groups differed in average term of pregnancy or average weight of the twins. Average age of the mothers differed at 5% level of significance (average age values were 30.16 for the group with reduction and 31.73 for the group without reduction). Fisher test on 5% significance level did not ascertain any significant difference in the probability of miscarriage between the group with reduction (5.26%) and the group without reduction (12.84%). At 5% level of statistical significance, no significant difference in probability of perinatal death of the foetus or delivery of a stillborn foetus was ascertained. However, it is necessary to point out a low frequency of these phenomena in our group. The percentage of cesarean sections did not differ significantly in both groups (86.24% in the group monitored vs 87.24% in the group of twins without reduction).

CONCLUSION

The analysis of both groups proves that reduction of multi-foetal pregnancies does not worsen perinatal results in comparison to pregnancies where reduction was not performed.

Increasing the diversity of medical data mining through distributed object technology

Data mining has been recently experiencing a boom of interest from researchers and software producers. In medicine, however, its applications are still rather rare. In this paper, we argue that this is primarily due to the requirements of reproducibility of results and diversity of available data mining tools, both of which are crucially important for medical research. We propose to tackle the diversity requirement by means of distributed object technologies. The results presented here rely on our experience with medical data mining using the method GUHA and with further developing that method.