Processing Medical Natural Language Data by the System WAREL

Many clinical data are in natural language form (diagnoses, therapies, etc.). There is great interest in making these data retrievable to form samples of patients for scientific investigations (statistical analyses, courses of diseases, etc.). To perform this task, “medical natural language data” have to be prepared and stored in a retrieval-oriented database. In this paper, the advantages of processing textual data are shown in contrast to coding. Accordingly, in our system WAREL medical thesauri (like ICD 9 or SNOMED) are not used for codification; they are taken as a knowledge base during the retrieval and for testing the quality of the data during documentation. The fundamental methods (computerized textual analysis and different algorithms for comparing texts) are explained in detail, and their realization within the system WAREL is illustrated (WAREL stands for Wiener Allgemeines Relationenschema).

ArchiMed: A Medical Information and Retrieval System

ArchiMed is a highly flexible medical data storage and retrieval system which adds sophisticated clinical research support to a standard hospital information system (HIS).

Currently, the HIS of Vienna General Hospital-University Hospital (2000 beds) stores the clinical data of over 2 million patients. While this system supports patient care (e.g., ADT, clinical chemistry, diagnosis, procedures), it has no features to facilitate research, such as the management of clinical studies.

ArchiMed is designed to support clinical research. It includes an independent database, which mirrors virtually all the information held in the HIS while also allowing new data to be collected independently and to be added to the database. Flexible retrieval and analysis of data contained in the database are then possible. Thus, existing patient data can be smoothly incorporated into a study together with data collected specifically for research purposes. The system has already been successfully installed in the departments of surgery and soon in other departments as well.

NSAIDs in paediatrics: caution with varicella!

Anti-inflammatory drugs have been suspected on several occasions to have promoted development of bacterial infection among varicella patients. Some countries have not implemented childhood varicella vaccination. Three cases in our hospital suggested the predisposing role of NSAIDs in varicella patient deterioration. Open access to these drugs widely increases their use and patient information should be continually provided in the medical offices and at dispensing pharmacy counters. Taking account of the benefit/risk balance and applying the simple precautionary principle, it would be appropriate to be cautious about the use of NSAIDs in the paediatric population.

Efficacy and safety of ipratropium bromide/albuterol delivered via Respimat inhaler versus MDI

We compared the efficacy and safety of ipratropium bromide/albuterol delivered via Respimat inhaler, a novel propellant-free inhaler, versus chlorofluorocarbon (CFC)-metered dose inhaler (MDI) and ipratropium Respimat inhaler in patients with COPD. This was a multinational, randomized, double-blind, double-dummy, 12-week, parallel-group, active-controlled study. Patients with moderate to severe COPD were randomized to ipratropium bromide/albuterol (20/100mcg) Respimat inhaler, ipratropium bromide/albuterol MDI [36mcg/206mcg (Combivent Inhalation Aerosol MDI)], or ipratropium bromide (20mcg) Respimat inhaler. Each medication was administered four times daily. Serial spirometry was performed over 6h (0.15min, then hourly) on 4 test days. The primary efficacy variable was forced expiratory volume in 1s (FEV(1)) change from test day baseline at 12 weeks. A total of 1209 of 1480 randomized, treated patients completed the study; the majority were male (65%) with a mean age of 64 yrs and a mean screening pre-bronchodilator FEV(1) (percent predicted) of 41%. Ipratropium bromide/albuterol Respimat inhaler had comparable efficacy to ipratropium bromide/albuterol MDI for FEV(1) area under the curve at 0-6h (AUC(0-6)), superior efficacy to ipratropium Respimat inhaler for FEV(1) AUC(0-4) and comparable efficacy to ipratropium Respimat inhaler for FEV(1) AUC(4-6). All active treatments were well tolerated. This study demonstrates that ipratropium bromide/albuterol 20/100mcg inhaler administered four times daily for 12 weeks had equivalent bronchodilator efficacy and comparable safety to ipratropium bromide/albuterol 36mcg/206mcg MDI, and significantly improved lung function compared with the mono-component ipratropium bromide 20 mcg Respimat inhaler. [Clinical Trial Identifier Number: NCT00400153].

[Use of injectable lorazepam in status epilepticus: a comparative study in French-speaking hospitals]

BACKGROUND

Injectable lorazepam (IL) is marketed in many countries but in France is only available within the framework of a compassionate use program for refractory status epilepticus. This study aims to evaluate the differences of pediatric use and status of IL in the hospitals of the Mother-Child French-speaking Network (Réseau mère-enfant de la francophonie, i.e., RMEF).

METHODS

Inclusion criteria are: firstly, RMEF member; secondly, one site per town; thirdly, all the Assistance publique-Hôpitaux de Paris hospitals. After a phone-recruitment in each selected hospital, a survey was sent by e-mail. The data collected concerned the number of beds in the hospital, the official status of IL, its place in the therapeutic strategy, in hospital consumption in 2008 (in milligram) and the therapeutic alternatives.

RESULTS

Among the 18 hospitals selected, 17 were contacted and 12 (70%) replied. IL is not marketed in Tunisia and Lebanon. In Switzerland, Canada and Belgium, IL is marketed and used in all the polled hospitals (6.2 to 48.0mg per bed). In France, only the Robert Debré Hospital uses it (3.2mg per bed). In the countries where it is marketed, IL was firstly prescribed for the studied indication. In the other countries, injectable diazepam was the first line treatment (six out of eight hospitals).

DISCUSSION/CONCLUSION

France is the only country where IL is available though not marketed. The pharmacokinetic data favor use of IL instead of its principal therapeutic alternative (injectable diazepam) but no currently available evidence concludes that IL is superior to diazepam in the management of pediatric status epilepticus. The official indication of IL in France (last intention) is in contradiction with its use in the countries where it is marketed and with the data of the literature in favor of the first intention. This works presents the first evaluation on the use of IL in pediatric status epilepticus in the RMEF hospitals. It highlights the discrepancies in the management of status epilepticus in comparable pediatric hospitals.

Le syndrome d’Aicardi-Goutières : une maladie neurologique infantile, à transmission familiale, encore méconnue

INTRODUCTION

Aicardi-Goutieres syndrome, first described in 1984, is a progressive infantile familial encephalopathy featuring cerebral calcifications, mainly of the basal ganglia, cerebral white matter abnormalities and cerebrospinal fluid lymphocytosis. Most of the patients present with severe developmental retardation, microcephaly, abnormal eye movements, pyramidal tract signs, and prominent dystonic movements. An elevated level of interferon-alpha in the CSF is a constant feature, particularly during the first stages of the disease course. One locus has been mapped on chromosome 3p21 in about half of the families so far studied.

PATIENTS

and results. We report two new French cases and discuss the limits of the clinical syndrome, the differential diagnosis and issues raised by the pathophysiological mechanisms involved. The major concern is to separate this condition from intrauterine infections because of the genetic and therapeutic consequences. A number of other questions remain unanswered. For example, we still do not know today at what age the absence of features like CSF lymphocytosis, and possibly absence of calcifications, rules out the diagnosis of the condition. The origin of the vasculitis lesions is not known, but seems to be related to dysregulation of interferon production and secretion.

CONCLUSION

Currently about 75 patients have been reported, even though many more probably exist. The study of this syndrome can contribute to the understanding of some mechanisms of CNS calcification and in a broader perspective to that of chronic encephalopathies with dysregulation of immune mechanisms.

[Antenatal corticosteroids: benefits and risks]

A favorable benefit-to-risk ratio is well established for a single dose of antenatal corticosteroids in women at risk of preterm delivery. The efficacy is real with an important decrease of mortality and morbidity. No adverse effects were described after one course. Possible beneficial effects of repeated courses include lower rates of RDS and a decrease in oxygen use, whereas an increasing body of evidence raises the concern of multiple short and long term adverse consequences, principally neurological. It seems rational to prescribe one course of corticosteroids. The indication for a second course should be discussed but multiples courses of this treatment should not be prescribed. We prefer betamethasone over dexamethasone because of the better side profile. Further work is needed to understand the long-term effects of this treatment.

Extracting a statistical data matrix from electronic patient records

This paper describes the processing and transformation of medical data from a clinical database to a statistical data matrix. Precise extraction and linking tools must be available for the desired data to be processed for statistical purposes. We show that flexible mechanisms are required for the different types of users, such as physicians and statisticians. In our retrieval tools we use logical queries based on operands and operators. The paper describes the method and appliance of the operators with which the desired matrix is created through a process of selection and linking. Examples with a Kaplan-Meier function and time-dependent covariables demonstrate how our model is useful for different user groups.

Incorporating family and social structures into clinical documentation and retrieval

Referencing familial and social relationships between patients supplies valuable information for the retrieval and interpretation of clinical data. We present a technique for the incorporation of patient relations into data retrieval that takes into account the specific properties of routinely collected clinical data. In most clinical databases, family relations are documented in a fragmentary manner at best. Furthermore, clinical retrieval systems do not support inter-patient queries in most cases. Our model is designed to formulate direct relations between patients and to identify patients as members of either temporary or persistent communities. In this way, the model supplies information on both genetic and social relations.

Unambiguous identification of hospital patients: case study at the university departments of the General Hospital, Vienna

This article considers the problem of identifying patients in one or more heterogeneous personal databases. The unambiguous identification of patients is an essential prerequisite for an efficient patient care system. We discuss the problems involved in this task and suggest how they can be dealt with. The solution of automatic consolidation of patient records sequires programming, organisational and work psychology measures. Following a survey of conventional identification methods, the method developed at the Department of Medical Computer Sciences, which is based on the current clinical situation at the General Hospital in Vienna (AKH--Allgemeines KrankenHaus), is described in detail. The basic principle is to identify patients unambiguously by means of an ID (IZAHL) derived directly from the personal data. Thereby a deterministic technique without probability weighting is used-all compared information must correspond completely. The article closes with a critical survey of experience gathered to date.

A retrieval system for the selection and statistical analysis of clinical data

Within the last years computer-aided clinical documentation has provided researchers and administrators with very large volumes of data for research. User-friendly retrieval tools are needed when processing these clinical databases. Clinical researchers require applications by means of which steps in selection and analysis can be performed in an iterative process. During the deduction of statistical parameters from routinely collected data a number of problems occur that do not appear in the analysis of data gathered within clinical studies. Unlike clinical studies, routine data have complex structures and must first be formatted and above all temporally synchronized. In this paper we will describe the medical retrieval system ArchiMed developed at the Vienna General Hospital. A main objective in the design of this system was to support a joint evaluation of data from clinical studies and routinely collected data. The retrieval system comprises the main functions: Selection of Patients; Selection and Joining of Variables; and Statistical Analysis.

ArchiMed: a medical information and retrieval system

ArchiMed is a highly flexible medical data storage and retrieval system which adds sophisticated clinical research support to a standard hospital information system (HIS). Currently, the HIS of Vienna General Hospital-University Hospital (2000 beds) stores the clinical data of over 2 million patients. While this system supports patient care (e.g., ADT, clinical chemistry, diagnosis, procedures), it has no features to facilitate research, such as the management of clinical studies. ArchiMed is designed to support clinical research. It includes an independent database, which mirrors virtually all the information held in the HIS while also allowing new data to be collected independently and to be added to the database. Flexible retrieval and analysis of data contained in the database are then possible. Thus, existing patient data can be smoothly incorporated into a study together with data collected specifically for research purposes. The system has already been successfully installed in the departments of surgery and soon in other departments as well.

Chronic intestinal pseudo-obstruction syndrome in pediatrics. Results of a national survey by members of the North American Society of Pediatric Gastroenterology and Nutrition

A total of 87 cases of chronic intestinal pseudo-obstruction were identified as fitting the criteria for the syndrome. Five families, three with autosomal dominant inheritance, accounted for 15 cases. The remainder were single cases in families, indicating either autosomal recessive inheritance, spontaneous mutation, or acquired disease. Of the 87 patients, 47 were male; 19 patients were symptomatic at birth and 37 (43%) within the first month of life; 64% were diagnosed by the first year of age and the remainder were diagnosed by 18 years of age. Patients currently range in age from 3 months to 24 years. Abdominal distension in 70, vomiting in 50, and constipation in 50 of the 87 cases were the three commonest presenting symptoms. Diarrhea and failure to thrive were present in 20 cases. Urinary tract infection and failure to void were present in 10 cases. Diagnosis was established by clinical presentation, radiographic studies, and at exploratory laparotomy. Esophageal motility was abnormal in 14 patients. Anal manometric studies were done in 16 and showed normal recto-anal inhibitory reflex in all but one. Only 34 patients had biopsy studies as part of their evaluation and, of these, only 12 were full-thickness. Abnormal plexuses were found in eight and degeneration of smooth muscles in four. There was little or no benefit from the use of any medication to promote motility. One patient with intractable pseudo-obstruction benefited from a subtotal enterectomy. Of those patients not lost to follow-up, 31.4% died; 43% of these deaths occurred within the first 6 months from complications of total parenteral nutrition. One infant had a complete spontaneous remission by 1 year of age, with normalization of radiographic findings; another had partial remission by 6 months of age.

Transtentorial herniation with posterior cerebral artery territory infarction. A new mechanism of the syndrome of alexia without agraphia

A 39-year-old male developed a right homonymous hemianopsia and alexia without agraphia following emergency surgery for hemorrhage into a left frontal tumor. A computerized tomographic (CT) scan demonstrated low density areas in the left frontal region and in the territory of the left posterior cerebral artery. The alexia without agraphia syndrome appeared to result from compression of the left posterior cerebral artery by a transtentorial pressure cone, a mechanism not previously reported in this syndrome. The behavioral investigation confirmed the diagnosis and replicated recent findings related to the syndrome of alexia without agraphia.