Can 18F-FDG PET/CT findings be used to predict orbital tumor histology?

PURPOSE

To investigate whether 18F-FDG PET/CT might be useful to predict the histology of various orbital tumors based on the maximum standard uptake value (SUVmax) and the OMSUV (orbital max SUV)/MLSUV (mean liver SUV) ratio.

PATIENTS AND METHODS

A retrospective single-center study was conducted between May 2019 and December 2020. Patients with an orbital mass who underwent preoperative 18F-FDG PET/CT followed by an orbital biopsy were included. Tumor histology was classified as follows: orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor. Orbital tumors were also classified as indolent or aggressive. Data recorded included the orbital SUVmax, OMSUV/MLSUV ratio and additional extra-orbital SUV sites.

RESULTS

Forty-five patients (24 men) were included. There were 15 (33.3%), 14 (31.1%), 9 (20%), and 7 (15.5%) cases of orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor, respectively. No correlation was found between the OMSUV/MLSUV ratio and orbital SUVmax and tumor histology (Z = -0.77, Z = -0.6, Z = -1.6, and Z = 0.94, all P > 0.05, respectively). No correlation was found between the OMSUV/MLSUV ratio (Z = -1.42, P > 0.05) and orbital SUVmax (Z = -0.82, P > 0.05) and tumor aggressiveness (indolent versus aggressive). Subgroup analyses showed that SUVmax was predictive of lymphoma aggressiveness (P = 0.05) and was able to distinguish orbital cancers (all lymphomas+solid tumors) from benign tumors (P = 0.02).

CONCLUSION

18F-FDG PET/CT could not be used to predict the underlying orbital tumor histology. However, more aggressive tumors, especially high-grade lymphomas and cancers, tended to have a higher orbital SUVmax compared to indolent lesions.

[Impact of luteal phase support by human chorionic gonadotropin (hCG) in intrauterine inseminations]

OBJECTIVES

The objective of our study is to evaluate the impact of luteal phase support by hCG in intrauterine inseminations preceded by ovarian gonadotropin stimulation.

METHODS

A retrospective study was conducted at the CHU of Nice between March 1, 2016 and October 31, 2017. During this period, 300 intrauterine inseminations were included in data analysis. Ovarian stimulation was performed by gonadotropins and a GnRH antagonist was added, if needed. Following a modification of standard operative procedure in the department, patients who performed an intrauterine insemination from December 1, 2016 received luteal phase support with two injections of hCG 1500 IU, performed at three days of interval. Pregnancy and ovarian hyperstimulation syndrome were the primary and secondary study endpoints, respectively.

RESULTS

Out of 300 inseminations included in the analysis, 144 were performed with luteal phase support and 156 without support. No statistically significant difference in pregnancy rate was observed between these two groups (19.4% of pregnancy in the luteal phase support group and 15.38% in the group without luteal phase support, P=0.353). No ovarian hyperstimulation syndrome occurred over the course of the study.

CONCLUSION

Our study shows a slight improvement of pregnancy rate in the group subjected to luteal phase support by hCG after intrauterine insemination, but the benefit was not significant. A randomised prospective study based on a large cohort could help to assess the effect of luteal phase support during intrauterine inseminations.

Medical Decision Support Systems: Old Dilemmas and new Paradigms?

Objectives: The purpose of this paper is to examine past and present medical decision support systems and the environment in which they operate and to propose specific research tracks that improve integration and adoption of these systems in today’s health care systems.

Methods: In preamble, we examine the objectives, decision models, and performances of past decision support systems.

Results: Medical decision support tools were essentially formulated from a technical capability perspective and this view has met limited adoption and slowed down new development as well as integration of these important systems into patient management work flows and clinical information systems. The science base of these systems needs to include evidence-based medicine and clinical practice guidelines and the paradigms need to be extended to include a collaborative provider model, the users and the organization perspectives. The availability of patient record and medical terminology standards is essential to the dissemination of decision support systems and so is their integration into the care process.

Conclusion: To build new decision support systems based on practice guidelines and taking into account users preferences, we do not so much advocate new technological solutions but rather suggest that technology is not enough to ensure successful adoption by the users, the integration into practice workflow, and consequently, the realisation of improved health care outcomes.

Confidentiality Issues within a Clinical Information System: Moving from Data-driven to Event-driven Design

Within a hospital, the moving of medical information systems from retrospective data-gathering methods to prospective clinical information systems raises the question of the confidentiality of patient data. A method of improving the traditional matrix model usually used to achieve access controls is described. The event-driven model refers to the way a security system ensures that a given user has a valid »need-to« relationship to a given patient. Events are defined as the occurrence of specific data that trigger the creation or the updating of the relationship between the identity of a user and the identity of a patient (e. g., admission, discharge, transfer, prescription, and report). The creation and the deletion of the relationships between users and patients are based on numerous repositories and working lists of patients. This implementation requires an organization of the hospital activities which is able to manage, in a real-time manner, those repositories as closely as possible to the steps occurring during the patient’s care process. Although this approach seems to reasonably fit the dynamic of the care process, it adds significant organizational constraints.

Secondary Use of Recorded or Self-expressed Personal Data: Consumer Health Informatics and Education in the Era of Social Media and Health Apps

Objective: To summarize the state of the art during the year 2016 in the areas related to consumer health informatics and education with a special emphasis in secondary use of patient data. Methods: We conducted a systematic review of articles published in 2016, using PubMed with a predefined set of queries. We identified over 320 potential articles for review. Papers were considered according to their relevance for the topic of the section. Using consensus, we selected the 15 most representative papers, which were submitted to external reviewers for full review and scoring. Based on the scoring and quality criteria, five papers were finally selected as best papers Results: The five best papers can be grouped in two major areas: 1) methods and tools to identify and collect formal requirements for secondary use of data, and 2) innovative topics highlighting the interest of carrying on "secondary" studies on patient data, more specifically on the data self-expressed by patients through social media tools. Regarding the formal requirements about informed consent, the selected papers report a comparison of legal aspects in European countries to find a common and unified grammar around the concept of "data donation". Regarding innovative approaches to value patient data, the selected papers report machine learning algorithms to extract knowledge from patient experience and satisfaction with health care delivery, drug and medication use, treatment compliance and barriers during cancer disease, or acceptation of public health actions such as vaccination. Conclusions: Secondary use of patient data (apart from personal health care record data) can be expressed according to many ways. Requirements to allow this secondary use have to be harmonized between countries, and social media platforms can be efficiently used to explore and create knowledge on patient experience with health problems or activities. Machine learning algorithms can explore those massive amounts of data to support health care professionals, and institutions provide more accurate knowledge about use and usage, behaviour, sentiment, or satisfaction about health care delivery.

Health Social Media and Patient-Centered Care: Buzz or Evidence? Findings from the Section "Education and Consumer Health Informatics" of the 2015 Edition of the IMIA Yearbook

OBJECTIVE

To summarize the 2014 state of the art in the areas related to consumer health informatics and social media.

METHODS

We conducted a systematic review of articles published in 2014 in PubMed with a predefined set of queries. We identified 439 articles relevant for the review. The two section editors independently screened those papers taking into account their relevance to the topics covered by the section. In a second step, they jointly selected the 20 most representative papers as candidate best papers. Candidate best papers were then submitted for full review and scoring by external reviewers. Based on the scoring, section editors together with the IMIA Yearbook editorial board selected the four best papers published in 2014 in consumer health informatics.

RESULTS

Helping patients acquire a healthier lifestyle is a crucial part of patient empowerment. In this line of work, new studies are exploring the efficacy of online health interventions for patient behavioral change. The special case of smoking cessation for consumers with low socio-economic status is particularly noticeable. Another study has explored how an online intervention can reduce the anxiety of women who experience an abnormal mammography. The team of PatientsLikeMe has studied how online support groups could play a role in the quality of life of organ transplant recipients. The patient perspective of online forums' users is also analyzed in the domain of anticoagulation therapy.

CONCLUSIONS

Online health interventions, many of them using social media, have confirmed their potential to impact consumer behavioral change. However, there are still many methodological issues that need to be addressed in order to prove cost-effectiveness.

Creation of the First French Database in Primary Care Using the ICPC2: Feasibility Study

The objective of our study was to assess the feasibility of gathering data stored in primary care Electronic Health records (EHRs) in order to create a research database (PRIMEGE PACA project). The software for EHR models of two office and patient data management systems were analyzed; anonymized data was extracted and imported into a MySQL database. An ETL procedure to code text in ICPC2 codes was implemented. Eleven general practitioners (GPs) were enrolled as "data producers" and data were extracted from 2012 to 2015. In this paper, we explain the ways to make this process feasible as well as illustrate its utility for estimating epidemiological indicators and professional practice assessments. Other software is currently being analyzed for integration and expansion of this panel of GPs. This experimentation is recognized as a robust framework and is considered to be the technical foundation of the first regional observatory of primary care data.

All that Glitters Is not Gold: Consumer Health Informatics and Education in the Era of Social Media and Health Apps. Findings from the Yearbook 2016 Section on Consumer Health Informatics

OBJECTIVE

To summarize the state of the art published during the year 2015 in the areas related to consumer health informatics and education with a special emphasis on unintended consequences of applying mobile and social media technologies in that domain.

METHODS

We conducted a systematic review of articles published in PubMed with a predefined set of queries, which lead to the selection of over 700 potential relevant articles. Section editors screened those papers on the title, abstract, and finally complete paper basis, taking into account the papers' relevance for the section topic. The 15 most representative papers were finally selected by consensus between the two section editors and submitted for full review and scoring to external reviewers and the yearbook editors. Based on the final scoring, section editors selected the best five papers.

RESULTS

The five best papers can be grouped in two major areas: 1) Digital health literacy and 2) Quality and safety concerns. Regarding health literacy issues of patients with chronic conditions such as asthma, online interventions should rather focus on changing patient beliefs about the disease than on supporting them in the management of their pathology since personally controlled health management systems do not show expected benefits,. Nevertheless, encouraging and training chronic patients for an active online health information-seeking behaviour substantially decreases state anxiety level. Regarding safety and privacy issues, even recommended health-related apps available on mobile phones do not guarantee personal data protection. Furthermore, the analysis indicated that patients undergoing Internet interventions experienced at least one adverse event that might be related to treatment. At least, predictive factors have been identified in order to credit or not a health rumour.

CONCLUSIONS

Trusting digital and connected health can be achieved if patients, health care professionals, and industrials build a shared model of health data management integrating ethics rules. Only increasing efforts in education with regards of digital health would help reach this goal., This would not resolve all frauds and security issues but at least improve their detection.

[Prosocial intervention in children and adolescents with autism spectrum disorder without intellectual disability: benefits of videotaping therapy sessions]

INTRODUCTION

The category of pervasive developmental disorders (PDD) without intellectual disability (including Asperger syndrome and high-functioning autism) has increased steadily among individuals since the 1980s. Although some symptoms may decrease with age, functional disability persists and is largely related to abnormalities in social interaction. Within the framework of PDD without intellectual disability, improving social skills appears to be a primary target for intervention programs. Despite a recent increase in the number of studies on this topic, few validated programs are yet available for clinical settings.

BACKGROUND

We have developed an intervention targeting the improvement of social skills from the analysis of video sequences. The goal of this intervention is to promote communication within the group through sharing their interests and emotions, and to enhance the understanding of social situations. In order to assess the efficiency of this intervention, we have conducted a prospective, open, and uncontrolled study. First, it aimed at assessing the immediate effect of our intervention on a single social skill (communication) in an experimental situation (in the group) and in an ecological situations (family and school). Second, this study aimed at assessing the effects of this intervention on the subjects' social adjustment.

METHOD

This study included 16 individuals with high-functioning autism/Asperger syndrome. Participants were evaluated before and after a 6-month video-based training using measures of socio-communicative and adaptive skills.

RESULTS

Results revealed a statistically significant increase in the communication skills not only in the group (15.5%), but also at home (13.7%) and at school (8.7%). The evaluation of socio-adaptive behavior indicates a statistically significant increase in communication (12%), family (7%) and social autonomy (8%), and leisure activities (8%).

DISCUSSION

The communication and social adjustment scores obtained upon inclusion were low, despite low autistic intensity scores. However, the improvement at six months was significant for most studied variables. These results are consistent with our clinical findings and seem partly explained by the use of video supports as the mediator of exchanges within the group. However, because of some methodological limitations, the conclusions on the effects of the intervention should be nuanced.

CONCLUSIONS

This type of intervention seems to be an interesting therapeutic indication for individuals with high-functioning autism/Asperger syndrome. The first results are encouraging, and all participants enjoyed attending the meetings. These conclusion elements encourage us to continue this intervention and to pursue further research by studying the impact on the individuals' quality of life.

Social media and patient health outcomes. Findings from the yearbook 2014 section on consumer health informatics

OBJECTIVES

To provide a review of the current excellent research published in the field of Consumer Health Informatics.

METHOD

We searched MEDLINE® and WEB OF SCIENCE® databases for papers published in 2013 in relation with Consumer Health Informatics. The authors identified 16 candidate best papers, which were then reviewed by four reviewers.

RESULTS

Five out of the 16 candidate papers were selected as best papers. One paper presents the key features of a system to automate the collection of web-based social media content for subsequent semantic annotation. This paper emphasizes the importance of mining social media to collect novel data from which new findings in drug abuse research were uncovered. The second paper presents a practical method to predict how a community structure would impact the spreading of information within the community. The third paper presents a method for improving the quality of online health communities. The fourth presents a new social network to allow the monitoring of the evolution of individuals' health status and diagnostic deficiencies, difficulties or barriers in rehabilitation. The last paper reports on teenage patients' perception on privacy and social media.

CONCLUSION

Selected papers not only show the value of using social media in the medical field but how to use these media to detect emergent diseases or risks, inform patients, promote disease prevention, and follow patients' opinion on healthcare resources.

[Biometric and biomechanic analysis of lumbar posterior facets based on a CT-scan database]

AIM OF THE STUDY

Our knowledge on anatomy of lumbar spine is based on few cadaver's study with old and few subjects. CT-scan is very precise for lumbar facet's morphology. We have analysed 400 subjects. The aim of this study is to measure different distances, angles and circles to better understand the mechanical function of the lumbar facets.

PATIENTS AND METHODS

We have analysed 720 CT-scan. We had 217 men and 183 women with 59 years of mean age. We used native slices of 1.25 mm thick from L1 to S1. We created transversal plan and we put different mark point. We took their coordinates and we have calculated different distances, angles and mechanical circles. We have compared different axis of rotation of the facets.

RESULTS

From L1 to S1, the facets goes near to the posterior wall and far from themselves. Moreover, the posterior angle between both facets increase down to the sacrum. The radius of the left side circle and the right one are very closed in 50% of the cases but the three radius are close only in 10% of cases.

CONCLUSION

This study based on 400 subjects shows that there is not a unique axis of rotation for both lumbar posterior facets. We have had only 50% of symmetry between both sides whatever the level studied.

Evidence-based Practice. Findings from the Section on Education and Consumer Health Informatics

OBJECTIVES

To provide an overview of outstanding current research conducted in Education and Consumer Informatics.

METHOD

Synopsis of the articles on education and consumer health informatics published in 2012 and selected for the IMIA Yearbook of Medical Informatics 2013.

RESULTS

Architecture of monitoring or telehealth information systems for patients with chronic disease must include wireless devices to aid in the collection of personal data. Data acquisition technologies have an impact on patients' willingness to participate in telehealth programmes. Patients are more likely to prefer mobile applications over web-based applications. Social media is widely used by clinicians. Especially younger clinicians use it for personal purposes and for reference materials retrieval. Questions remain on optimal training requirements and on the effects on clinician behavior and on patient outcomes. A high level of e-Health literacy by patients will promote increased adoption and utilization of personal health records.

CONCLUSION

The selected articles highlight the need for training of clinicians to become aware of existing telehealth systems, in order to correctly inform and guide patients to take part in telehealth systems and adopt personal healthcare records (PHR).

Un portfolio électronique structuré pour la gestion et le suivi des dossiers d’évaluation des pratiques professionnelles en technique et médecine transfusionnelles

In order to organize a nationwide program for the evaluation of professional practices in the area of blood transfusion, the French National Blood Transfusion Institute and the Nice-Sophia Antipolis University designed and implemented a web based service aimed at following-up and guiding the physicians involved in such an assessment program. The core component is a structured electronic portfolio (ePortfolio), the implementation of which was based on an object-oriented environment combined with a content management system. The modelling of the global evaluation system makes it possible to describe this type of portfolio according to six axes: an axis "objectives" (competencies accreditation); an axis "target" (heath care professionals); an axis "content" (numerical documents); an axis "structure" (matrix of answer defined in space and time); an axis "source" (single source peer-reviewed); an axis "level of evidence" (validation of the proof after its deposit by an identified and authenticated peer user, whole tracking of the exchanges and interactions between users and device).

[Transcatheter embolization for endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage]

OBJECTIVES

Evaluate the efficacy of endovascular embolization for patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage as well as the factors that may influence mortality. MATERIALS AND METHODS. Retrospective study over a 4-year period including a historical cohort of 37 consecutive patients (22 men), with a mean age of 69.2 years (range, 22-93 years). In most cases (54%), the hemorrhage stemmed from a gastrointestinal ulcer. Technical, primary clinical, and secondary clinical success rates, as well as complication rates, were calculated. Several clinical and angiographic parameters were compared to the early mortality rate using Kruskal-Wallis or Fisher tests.

RESULTS

Technical, primary clinical, secondary clinical success rates, and complication rates were, respectively, 89.2%, 83.8%, 88.9%, and 10.8%. The early mortality rate was 32.4%. The APACHE II and IGS II scores were strongly correlated with mortality (p=0.001 and p=0.003, respectively).

CONCLUSION

Endovascular embolization in patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage is effective. However, the mortality rate remains high because of the changes in the clinical condition of these patients.

Sex determination from the distal part of the femur in a French contemporary population

Until now, determining the sex of a recently deceased individual using the measurement of the bicondylar breadth of the femur (also known as condylar width, epicondylar breadth and distal epiphyseal breadth) raised some concerns as to accuracy because no sample of contemporary French subjects was available. In this study, a sample of 88 female and male femurs taken from recently deceased elderly French people was studied. The bones were collected from subjects who had donated their bodies to the Medical School of Nice. The mean value of the male bicondylar breadth was found to be greater than that of females (84.3mm versus 74.8mm), confirming the sexual dimorphism of this parameter. Furthermore, the results showed a 95.4% accuracy rate for sexing individuals. To date, in the French population, as in some other samples, epicondylar breadth is the single most accurate measurement of sex determination, ahead even of head diameter. A discriminant function is presented to allow sex determination from remains of the distal femur. With regard to the data available in the literature, sexual dimorphism is probably the result of both genetic and environmental factors. The comparison of our results with those of other populations shows that there are inter-population variations of the bicondylar breadth, and also intra-population variations that account for the differences in the accuracy rate of this variable for the purposes of sex determination. These findings underscore the need to re-evaluate bone measurements within various contemporary populations.

Tissue-specific differential antitumour effect of molecular forms of fractalkine in a mouse model of metastatic colon cancer

BACKGROUND AND AIMS

Fractalkine, a chemokine that presents as both a secreted and a membrane-anchored form, has been described as having tumour-suppressive activities in standard subcutaneous models. Here, we investigate the antitumour effect of fractalkine, in its three molecular forms, in two orthotopic models of metastatic colon cancer (liver and lung) and in the standard subcutaneous model.

METHODS

We have developed models of skin tumours, liver and pulmonary metastasis and compared the extent of tumour development between C26 colon cancer cells expressing either the native, the soluble, the membrane-bound fractalkine or none.

RESULTS

The native fractalkine exhibits the strongest antitumour effect, reducing the tumour size by 93% in the skin and by 99% in the orthotopic models (p<0.0001). Its overall effect results from a critical balance between the activity of the secreted and the membrane-bound forms, balance that is itself dependent on the target tissue. In the skin, both molecular variants reduce tumour development by 66% (p<0.01). In contrast, the liver and lung metastases are only significantly reduced by the soluble form (by 96%, p<0.002) whereas the membrane-bound variant exerts a barely significant effect in the liver (p = 0.049) and promotes tumour growth in the lungs. Moreover, we show a significant difference in the contribution of the infiltrating leukocytes to the tumour-suppressive activity of fractalkine between the standard and the orthotopic models.

CONCLUSIONS

Fractalkine expression by C26 tumour cells drastically reduces their metastatic potential in the two physiological target organs. Both molecular forms contribute to its antitumour potential but exhibit differential effects on tumour development depending on the target tissue.

L’escarre à l’hôpital en 2003 : enquête de prévalence un jour donné

BACKGROUND

To determine the prevalence of pressure sores in a university hospital and to assess the risk of developing a pressure sore.

METHODS

A one-day survey was performed in all hospitalized patients, day hospital excepted. The Garches scale was used to assess the severity of pressure sores and the Braden scale was used to measure the patient's risk for the development of pressure ulcers.

RESULTS

One thousand six hundred and eleven patients were included, mean age was 62+/-23 years and 53.3% were over 65 years old. In hospitalized patients, 64% were in acute care, 29% in intermediate medicine and long-term care and 7% in intensive care units. We have found 675 pressure sores in 268 patients, mean age of 76 years; 263 decubitus ulcers were acquired during hospitalization. The most frequent sites were heels (46%) and sacrum (26%). Stage 1 pressure ulcers showed 33% of the total. The total prevalence was 16.6%, 95% CI (14.9-18.6), the hospital acquired pressure sores prevalence was 7.5%, all stages included. A Braden score less than or equal to 15 was found in 29.1% of hospitalized patients. Standard mattresses were used in 37% of patients with pressure sores. Multivariate analysis showed that age and a Braden score less than or equal to 15 were significantly associated with pressure sores.

CONCLUSION

Pressure sores are still an important problem in hospital; occurrence must be considered as an iatrogenic event and management requires a multidisciplinary approach.

[Delayed diagnosis of inferior cervical spine injury]

PURPOSE OF THE STUDY

According to data in the literature, traumatic injury of the inferior cervical spine is not recognized in 4.5 to 33% of victims. The purpose of our study was to evaluate the rate of delayed diagnosis, search for causes, and propose a diagnostic approach.

MATERIAL AND METHODS

This prospective study included 284 patients recruited by eleven referral centers between November 1999 and March 2001. Each participating center completed a data chart and classified lesions. Exclusion criteria were whiplash without neurological disorder and without imaging anomaly, spinal ankylosis, and trauma more than three weeks before the first examination.

RESULTS

Among the 284 patients included, 240 had a unique lesion of the inferior cervical spine, 44 had multiple injuries. In all, 338 spinal lesions were recorded. There were 35 patients with multiple trauma injuries and 95 patients with spinal cord injuries. Time to diagnosis was less than 24 hours for 211 patients (74%), one day to one week for 38 patients (14%), and more than one week for 35 patients (12%). Defective management was noted in 13% of the cases. Late diagnosis was considered to have had a prejudicial effect in nine patients (3%). There was no correlation between time to diagnosis and type of lesion, level of lesion, or presence of multiple injuries.

DISCUSSION

Late diagnosis of inferior cervical spine injury can be an inevitable result of the context. This is particularly true for patients with multiple injuries or patients with purely discal or ligament injuries whose first manifestations occur late after the trauma. Beyond these specific situations, there is no logical explanation for late diagnosis other than insufficient diagnostic management. Spinal injury should always be suspected in trauma victims and the initial neurological status must be noted. If the subject is conscious, plain x-rays should be obtained in the event of pain in the cervical spine. A computed tomography is the exploration of choice. Dynamic views should be performed in all cases to search for pure ligament injury. The correct time for such explorations can only be determined on an individual basis. If the patient is unconscious, standard procedure includes x-ray of the cervical spine, and computed tomography of the skull-spine junction and the cervico-thoracic spine. Widespread systematic use of spiral and multiple array computed tomography should limit the number of late diagnoses.

CONCLUSION

Late diagnosis of inferior cervical spine injury is probably not uncommon. Improved management can be achieved through better medical awareness, better knowledge of cervical spine injuries, and routine imaging in application of the rule of prudence.

One-year longitudinal evaluation of neuropsychiatric symptoms in Alzheimer's disease. The REAL.FR Study

Behavioral and Psychological Symptoms are major and frequent manifestations of Alzheimer's Disease (AD). The aim of the present study was to evaluate neuropsychiatric symptoms in the PHRC REAL.FR cohort (for Réseau sur la maladie d'Alzheimer Français) after one year of evolution. Four hundred and eighty two patients with mild and moderate AD were assessed. A majority of them had significant symptoms at inclusion (85.3 % of subjects with mild AD, 89.7% of patients with a moderate AD). Patients with mild AD had a significant increase of the Neuropsychiatric Inventory (NPI) frequency x severity scores for apathy and aberrant motor behavior. Patients with moderate AD had a significant increase of NPI disinhibition, aberrant motor behavior and sleep disorders scores. The variation of NPI total score at one year correlated positively with change in Zarit's caregiver burden score, independently of global cognitive evolution. After one year, a group of 54 patients were institutionalized in nursing home or long term care unit. When compared to non institutionalized patients, the institutionalized group was characterized at base line by a lower MMSE score, a higher Zarit caregiver burden score, and a higher NPI agitation and disinhibition scores.

[How the information system can contribute to the implementation of a risk management program in a hospital?]

Nowadays, information system is recognised as one of the key points of the management strategy. An information system is regarded conceptualised as a mean to link 3 aspects of a firm (structure, organisation rules and staff). Its design and implementation have to meet the objectives of medical and economical evaluation, especially risk management objectives. In order to identify, analyse, reduce and prevent the occurrence of adverse events, and also to measure the efficacy and efficiency of the production of care services, the design of information systems should be based on a process analysis in order to describe and classify all the working practices within the hospital. According to various methodologies (usually top-down analysis), each process can be divided into activities. Each activity (especially each care activity) can be described according to its potential risks and expected results. For care professionals performing a task, the access to official or internal guidelines and the adverse events reporting forms has also to be defined. Putting together all the elements of such a process analysis will contribute to integrate, into daily practice, the management of risks, supported by the information system.

État nutritionnel et maladie d' Alzheimerrésultats préliminaires de l'étude REAL.FR

Weight loss is common in elderly people with dementia, particularly those with Alzheimer' disease (AD), and feeding difficulties are major issues in their care in the later stages of the disease. In this study (REAL FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Mini Nutritional Assessment (MNA) to examine the nutritional status of 479 subjects. Three groups of patients were studied: group 1 = 22 patients with undernutrition (MNA = 17), group 2 = 166 patients with risk of undernutrition (17 < MNA < 24), and group 3 = 291 patients without undernutrition (MNA = 24). Correlations with behavioral and psychological signs and symptoms of dementia (Neuropsychiatric Inventory NPI), with caregiver distress (Zarit), and with the Mini Mental State Examination (MMSE) were studied. Undernutrition is more frequently associated with low MMSE (p < 0.001), high behavioural disturbances (p < 0.001) and high distress of caregivers (p < 0.001). Risk of undernutrition is also associated with NPI (p < 0.001) and Zarit (p < 0.001). These first results in a French cohort of patients with AD underline the importance of the evaluation of nutritional status and finally the follow-up of eating behavior, cognitive status and the quality of life of the caregivers.

Symptômes comportementaux et psychologiques dans la maladied' Alzheimer : résultats de l'étude REAL.FR

Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) are important manifestations of Alzheimer's Disease (AD) and other forms of dementia, because they are associate with care-giver distress, increase the likelihood of institutionalization, and may be associated with more rapid cognitive decline In this study (REAL.FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Neuropsychiatric Inventory NPI to examine BPSD. 255 AD patients with a Mini-Mental State Examination (MMSE) score between 11 and 20 and 244 AD patients with a MMSE between 21 and 30 were examined. Factor analysis was carried out leading to three different syndromes according to the level of cognitive impairment. BPSD were detected in 92.5% of the patients with a MMSE between 11 and 20, and in 84% of the patients with a MMSE between 21 and 30. Apathy was the most common abnormality, followed by anxiety and dysphoria. These results in a French cohort of patients with AD underline the importance of the evaluation and finally of the treatment of BPSD.

Medical decision support systems: old dilemmas and new paradigms?

OBJECTIVES

The purpose of this paper is to examine past and present medical decision support systems and the environment in which they operate and to propose specific research tracks that improve integration and adoption of these systems in today's health care systems.

METHODS

In preamble, we examine the objectives, decision models, and performances of past decision support systems.

RESULTS

Medical decision support tools were essentially formulated from a technical capability perspective and this view has met limited adoption and slowed down new development as well as integration of these important systems into patient management work flows and clinical information systems. The science base of these systems needs to include evidence-based medicine and clinical practice guidelines and the paradigms need to be extended to include a collaborative provider model, the users and the organization perspectives. The availability of patient record and medical terminology standards is essential to the dissemination of decision support systems and so is their integration into the care process.

CONCLUSION

To build new decision support systems based on practice guidelines and taking into account users preferences, we do not so much advocate new technological solutions but rather suggest that technology is not enough to ensure successful adoption by the users, the integration into practice workflow, and consequently, the realisation of improved health care outcomes.

Reexamination of a measurement for sexual determination using the supero-inferior femoral neck diameter in a modern European population

The present study reexamines the accuracy of the supero-inferior femoral neck diameter for the determination of sex using a modern sample of French individuals. In 1998, Seidemann et al. used this univariate method for sex determination with the Hamann-Todd collection. Stojanowski and Seidemann in 1999 tested previous results on a modern sample taken from the University of New Mexico and concluded that the Caucasian male samples exhibited no significant differences between individuals born before and after 1900, but the Caucasian female subgroup did exhibit differences with an increase of the SID in the modern sample. The current study compares the previous results of the supero-inferior femoral neck diameter with a modern sample of elderly French individuals born after 1910. Both sides of the femur were measured. No statistical difference was found between the right and left side (p = 0.31). The results showed a significant difference between the pre-1900 and the modern sample, with an increase in femoral neck diameter in modern populations. The comparison of the SID values between the two modern samples (Mexico and Nice) showed no significant differences in the femoral neck diameter in the two male subgroups (p = 0.05), but the measurements of the SID in the female subgroup did exhibit significant differences with an increase of the neck femoral diameter (p < 0.01) in the modern French population. These results demonstrate an increase in the neck femoral morphology in the elderly European French females samples.

Comparison of the effects of sevoflurane and propofol on cortical somatosensory evoked potentials

BACKGROUND

Propofol (P) and sevoflurane (S) are potential anaesthetic agents if electrophysiological monitoring is required during spinal surgery. They allow rapid recovery and do not depress cortical somatosensory evoked potentials (SSEP) as much as other agents. The effects of these agents on SSEP have not been compared before.

METHODS

Twenty-four patients were allocated randomly to receive either S (n = 12) or P (n = 12). SSEP evoked by electrical stimulation of the posterior tibial nerve at the ankle were recorded before anaesthesia. The cortical potential P40 was recorded (latency P40 and amplitudes N29P40 and P40N50). The anaesthetic concentration was adjusted gradually to obtain three predetermined ranges of values of bispectral index (BIS): 45-55, 35-45 and 25-35. For each range, a stable state was maintained for 10 min and SSEP were recorded.

RESULTS

For the BIS 45-55 range, compared with preoperative values, P40 latency increased during S [mean change +2 (SD 0.6) ms] but not during P [+0.4 (0.2) ms (P = 0.12)] and both amplitudes (N29P40 and P40N50) decreased with S. Increasing S concentration caused a dose-dependent depression of SSEP. P did not have a statistically significant effect on the recordings and the signals remained stable in each BIS range.

CONCLUSION

Sevoflurane affected SSEP recordings in a dose-dependent fashion. Propofol had a minimal effect on SSEP recordings.

Subcutaneous or intrahepatic injection of suicide gene modified tumour cells induces a systemic antitumour response in a metastatic model of colon carcinoma in rats

BACKGROUND

Suicide gene therapy consists of the transfer into tumour cells of a "suicide" gene that can convert a non-toxic compound into a lethal drug. Expression of the cytosine deaminase gene leads to the conversion of the non-toxic compound 5-fluorocytosine to 5-fluorouracil. We have recently shown that "suicide cell based vaccination" consisting of intrahepatic injection of cytosine deaminase expressing colon cancer cells followed by 5-fluorocytosine treatment induces regression of a distant wild-type liver tumour in rats.

AIMS

This study was conducted to test if (i) a distant bystander effect on a liver tumour can be induced after subcutaneous suicide cell based vaccination and (ii) suicide cell based vaccination is efficient in limiting tumour dissemination to extrahepatic compartments.

METHODS

An aggressive variant of rat colon carcinoma cells was selected after successive passages in vitro. Rats carrying an experimental liver "metastasis" generated by injection of these cells were vaccinated by subcapsular or subcutaneous injection of cytosine deaminase expressing cells followed by 5-fluorocytosine treatment.

RESULTS

Subcutaneous and subcapsular vaccination induced 70% regression in the median volume of the pre-established liver tumour (p=0.001) and abolished tumour dissemination compared with control animals.

CONCLUSIONS

This study has compared for the first time the efficiency of subcutaneous and intrahepatic suicide cell based vaccination in a metastatic colorectal carcinoma model in rats. The results indicate that both modes of vaccination are equally efficient in inducing a systemic antitumour response, suggesting that this strategy is a powerful approach against the development and dissemination of metastatic colon carcinoma.

Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design

Healthcare institutions are looking at ways to increase their efficiency by reducing costs while providing care services with a high level of safety. Thus, hospital information systems have to support quality improvement objectives. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualise clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the blood transfusion process. An object-oriented data model of a process has been defined in order to organise the data dictionary. Although some aspects of activity, such as 'where', 'what else', and 'why' are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for the processes to be interrelated, and for their characteristics to be shared, in order to avoid data redundancy and to fit the gathering of data with the provision of care.

Improvement of 'dynamic analgesia' does not decrease atelectasis after thoracotomy

There is still controversy concerning the beneficial aspects of 'dynamic analgesia' (i.e. pain while coughing or moving) on the reduction of postoperative atelectasis. In this study, we tested the hypothesis that thoracic epidural analgesia (TEA) prevents these abnormalities as opposed to multimodal analgesia with i.v. patient controlled analgesia (i.v. PCA) after thoracotomy. Fifty-four patients undergoing thoracotomy (lung cancer) were randomly assigned to one of the two groups. Clinical respiratory characteristics, arterial blood gas, and pulmonary function tests (forced vital capacity and forced expiratory volume in 1 s) were obtained before surgery and on the next 3 postoperative days. Atelectasis was compared between the two groups by performing computed tomography (CT) scan of the chest at day 3. Postoperative respiratory function and arterial blood gas values were reduced compared with preoperative values (mean (SD) FEV1 day 0: 1.1 (0.3) litre; 1.3 (0.4) litre) but there was no significant difference between groups at any time. PCA and TEA provided a good level of analgesia at rest (VAS day 0: 21 (15/100); 8 (9/100)), but TEA was more effective for analgesia during mobilization (VAS day 0: 52 (3/100); 25 (17/100)). CT scans revealed comparable amounts of atelectasis (expressed as a percentage of total lung volume) in the TEA (7.1 (2.8)%) and in the i.v. PCA group (6.71 (3.2)%). There was no statistical difference in the number of patients presenting with at least one atelectasis of various types (lamellar, plate, segmental, lobar).

Value of stent placement during percutaneous transluminal angioplasty of the iliac arteries

BACKGROUND

To determine the benefits of stents during percutaneous transluminal angioplasty (PTA) of the iliac arteries. Retrospective analysis of our 10-year surgical experience with iliac PTA from 1988-1997 permitted comparison of results during two consecutive periods: an initial period (1988-1992), during which stents were never used, followed by a second period (1992-1997), when stenting was performed on indication.

METHODS

From January 1988 to October 1997, 287 iliac PTA procedures (158 common iliac arteries, 129 external iliac arteries) were performed on 250 patients. Thirty-seven patients had two iliac lesions that were treated simultaneously. Indications for PTA included stenosis (270 cases) and chronic occlusion (17 cases). Thirty-one patients (12.4%) underwent infra-inguinal bypass in addition to PTA owing to the existence of arterial lesions at two levels. Two consecutive patient groups were defined: Group I consisted of 75 patients who underwent 86 iliac PTA procedures between January 1988 and May 1992 without stent placement; Group II consisted of 175 patients who underwent 201 iliac PTA procedures between June 1992 and October 1997, when selective stenting was performed. A total of 55 stents (35 in the common iliac artery, 20 in the external iliac artery) were placed in Group II during PTA due to unsatisfactory immediate results (dissection, residual stenosis) or occlusion.

RESULTS

There was no 30-day mortality. There were 15 immediate failures of PTA: 8 in Group I (10.7%) and 7 in Group II (4%). The cumulative initial success rate was 94%. Follow-up ranged from 3 months to 102 months (mean 37 months). The cumulative primary patency rate at 4 years was 62% (58% in Group I, 64% in Group II). The cumulative secondary patency rate at 4 years (including patients who subsequently underwent repeat angioplasty procedures) was 72% (68% in Group I, 74% in Group II).

CONCLUSIONS

Stents were an effective means for treatment of initial failures of PTA in patients with iliac artery occlusive disease. However, there were no significant differences in the long term results between PTA alone and PTA with selective stent placement.

Modelling health care processes for eliciting user requirements: a way to link a quality paradigm and clinical information system design

Hospital information systems have to support quality improvement objectives. The design issues of health care information system can be classified into three categories: 1) time-oriented and event-labelled storage of patient data; 2) contextual support of decision-making; 3) capabilities for modular upgrading. The elicitation of the requirements has to meet users' needs in relation to both the quality (efficacy, safety) and the monitoring of all health care activities (traceability). Information analysts need methods to conceptualize clinical information systems that provide actors with individual benefits and guide behavioural changes. A methodology is proposed to elicit and structure users' requirements using a process-oriented analysis, and it is applied to the field of blood transfusion. An object-oriented data model of a process has been defined in order to identify its main components: activity, sub-process, resources, constrains, guidelines, parameters and indicators. Although some aspects of activity, such as "where", "what else", and "why" are poorly represented by the data model alone, this method of requirement elicitation fits the dynamic of data input for the process to be traced. A hierarchical representation of hospital activities has to be found for this approach to be generalised within the organisation, for the processes to be interrelated, and for their characteristics to be shared.

Impact of aortic diameter on the outcome of surgical treatment of abdominal aortic aneurysm

Several recent articles have discussed ultrasonographic surveillance of small abdominal aortic aneurysms (AAA). The purpose of this study was to evaluate the impact of lesion size on immediate morbidity and mortality after surgical treatment of AAA. More specifically we investigated whether the mortality rate was lower after treatment of AAA measuring

Do internal iliac arteries contribute to vascularization of the descending colon during abdominal aortic aneurysm surgery? An intraoperative hemodynamic study

The inferior mesenteric artery (IMA) is the nutrient artery for the descending colon. Colon ischemia after repair of abdominal aortic aneurysm (AAA) can be prevented by routine or elective revascularization of the IMA. In case of occlusion of the IMA, revascularization of the internal iliac artery (IIA) has been recommended but its effectiveness has never been documented. In this study, intraoperative hemodynamic monitoring of the IMA was performed to determine if the IIA contributed significantly to the region supplied by the IMA. From January 1998 to August 1999, a total of 223 patients underwent AAA repair at 11 vascular surgery centers. The IMA was occluded in 113 of these patients (51%). This study involves the other 110 patients (49%) with patent IMA. Study consisted of measuring residual systolic arterial pressure in the IMA (IMAP) immediately after AAA repair. To compensate for blood pressure variations, systolic pressure in the radial artery (RAP) was measured concurrently and the inferior mesenteric index (P) was calculated by dividing IMAP by RAP. Measurements were made before and during cross-clamping of the IIA to obtain two corresponding indexes-i.e., P1 and P2, respectively. Mean P1 and P2 were 0.61 (95% confidence interval, 0.8-0.4) and 0.58 (95% confidence interval, 0.55-0.61), respectively, with p

Designing and implementing medical web portals: spreading educational and research materials on the Internet

OBJECTIVES

To design and implement a medical web portal providing access to well qualified and high-quality information in the framework of universities and hospitals.

METHOD

Based on the authors experience and the published literature, a model is proposed which describes the properties of documents in an object-oriented way. This model clearly separates from usual properties: the subject of a document as keywords, and information concerning its type, format, and location.

RESULTS

An implementation has been done with an existing software that allows the capability to organize and index a web site according to the model. Experiments have been conducted which demonstrate the feasibility and the utility of such an approach.

DISCUSSION

The benefits for the users, both designers and end users, of using such a portal are discussed. Forthcoming works are described.

Towards health care process description framework: an XML DTD design

The development of health care and hospital information systems has to meet users needs as well as requirements such as the tracking of all care activities and the support of quality improvement. The use of process-oriented analysis is of-value to provide analysts with: (i) a systematic description of activities; (ii) the elicitation of the useful data to perform and record care tasks; (iii) the selection of relevant decision-making support. But paper-based tools are not a very suitable way to manage and share the documentation produced during this step. The purpose of this work is to propose a method to implement the results of process analysis according to XML techniques (eXtensible Markup Language). It is based on the IDEF0 activity modeling language (Integration DEfinition for Function modeling). A hierarchical description of a process and its components has been defined through a flat XML file with a grammar of proper metadata tags. Perspectives of this method are discussed.