Incremental value of heart-type fatty acid-binding protein in suspected acute myocardial infarction early after symptom onset.

BACKGROUND The early diagnosis of acute myocardial infarction (AMI) very soon after symptom onset remains a major clinical challenge, even when using high-sensitivity cardiac troponin (hs-cTnT). METHODS AND RESULTS We investigated the incremental value of heart-type fatty acid-binding protein (hFABP) in a pre-specified subgroup analysis of patients presenting with suspected AMI within 1 h of symptom onset to the emergency department (ED) in a multicentre study. HFABP was measured in a blinded fashion. Two independent cardiologists using all available clinical information, including hs-cTnT, adjudicated the final diagnosis. Overall, 1411 patients were enrolled, of whom 105 patients presented within 1 h of symptom onset. Of these, 34 patients (32.4%) had AMI. The diagnostic accuracy as quantified by the area under the receiver-operating characteristics curve (AUC) of hFABP was high (0.84 (95% CI 0.74-0.94)). However, the additional use of hFABP only marginally increased the diagnostic accuracy of hs-cTnT (AUC 0.88 (95% CI 0.81-0.94) for hs-cTnT alone to 0.90 (95% CI 0.83-0.98) for the combination; p=ns). After the exclusion of 18 AMI patients with ST-segment elevation, similar results were obtained. Among the 16 AMI patients without ST-segment elevation, six had normal hs-cTnT at presentation. Of these, hFABP was elevated in two (33.3%) patients. CONCLUSIONS hFABP does not seem to significantly improve the early diagnostic accuracy of hs-cTnT in the important subgroup of patients with suspected AMI presenting to the ED very early after symptom onset.

Diagnostic Accuracy of Copeptin in the Differential Diagnosis of the Polyuria-polydipsia Syndrome: A Prospective Multicenter Study

CONTEXT The polyuria-polydipsia syndrome comprises primary polydipsia (PP) and central and nephrogenic diabetes insipidus (DI). Correctly discriminating these entities is mandatory, given that inadequate treatment causes serious complications. The diagnostic "gold standard" is the water deprivation test with assessment of arginine vasopressin (AVP) activity. However, test interpretation and AVP measurement are challenging. OBJECTIVE The objective was to evaluate the accuracy of copeptin, a stable peptide stoichiometrically cosecreted with AVP, in the differential diagnosis of polyuria-polydipsia syndrome. DESIGN, SETTING, AND PATIENTS This was a prospective multicenter observational cohort study from four Swiss or German tertiary referral centers of adults >18 years old with the history of polyuria and polydipsia. MEASUREMENTS A standardized combined water deprivation/3% saline infusion test was performed and terminated when serum sodium exceeded 147 mmol/L. Circulating copeptin and AVP levels were measured regularly throughout the test. Final diagnosis was based on the water deprivation/saline infusion test results, clinical information, and the treatment response. RESULTS Fifty-five patients were enrolled (11 with complete central DI, 16 with partial central DI, 18 with PP, and 10 with nephrogenic DI). Without prior thirsting, a single baseline copeptin level >21.4 pmol/L differentiated nephrogenic DI from other etiologies with a 100% sensitivity and specificity, rendering a water deprivation testing unnecessary in such cases. A stimulated copeptin >4.9 pmol/L (at sodium levels >147 mmol/L) differentiated between patients with PP and patients with partial central DI with a 94.0% specificity and a 94.4% sensitivity. A stimulated AVP >1.8 pg/mL differentiated between the same categories with a 93.0% specificity and a 83.0% sensitivity. LIMITATION This study was limited by incorporation bias from including AVP levels as a diagnostic criterion. CONCLUSION Copeptin is a promising new tool in the differential diagnosis of the polyuria-polydipsia syndrome, and a valid surrogate marker for AVP. Primary Funding Sources: Swiss National Science Foundation, University of Basel.

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

Breastfeeding the very preterm hospitalized infant: An ethnographic study

Purpose. To develop a greater understanding of the experience—including the thoughts, feelings, and actions—of mothers' initiation and maintenance of lactation within the context of the NICU following the birth of a very preterm infant. ^ Design. Mixed method with dominant focused ethnographic approach. Setting: A 76-bed neonatal intensive care unit in the largest children's hospital located in a large metropolitan city in southeast Texas. ^ Sample. Purposeful sampling resulted in 23 interviews with 14 subjects. ^ Methods. Mixed method design with a dominant qualitative approach combined with a quantitative component to further identify and expand upon the investigation of the population in question. Open-ended semi-structured interviews and fieldwork were used to explore the experience of breastfeeding in the context of the NICU for mothers of very preterm infants. Longitudinal data obtained from each subject included in-depth interviews, demographic and clinical information, milk expression patterns (including pumping frequency, duration, and milk volumes obtained), and scores obtained from the Edinburgh Postpartum Depression Scale (EPDS). ^ Findings. Thematic analysis revealed that mothers of very preterm infants experienced an interruption in the process of becoming a mother, a paradoxical experience related to aspects of their milk expression routines and patterns, and negotiating the NICU environment. Sub-themes of becoming a mother-interrupted included: attribution, separation, connection, and navigation. Additional sub-themes related to the paradoxical experience included: the pump sometimes acting as a wedge or link to the infant; diversionary thoughts/activities during pumping; and perceptions of milk flow/volume. The process of negotiation included the environment, adaptive/maladaptive strategies related to milk expression, motivating factors related to the provision of breast milk, and learning their infant's feeding cues/abilities. EPDS scores did not reveal congruent differences in those mothers scoring high compared to those scoring low. ^ Conclusions. Understanding the experiences of the mothers in this study allows for a better perspective of breastfeeding the very preterm infant in the context of the NICU. Findings from this study validate the difficult and incremental process of attaining maternal identity and the significant burden placed on these women with regards to the provision of breast milk and breastfeeding during their infant's hospitalization. ^

Roadmap for implementing the Chronic Care Model for weight management: Healthcare Institution's Response to Obesity (HIRO)

Background. Excess weight and obesity are at epidemic proportions in the United States and place individuals at increased risk for a variety of chronic conditions. Rates of diabetes, high blood pressure, coronary artery disease, stroke, cancer, and arthritis are all influenced by the presence of obesity. Small reductions in excess weight can produce significant positive clinical outcomes. Healthcare organizations have a vital role to play in the identification and management of obesity. Currently, healthcare providers do not adequately diagnose and manage excess weight in patients. Lack of skill, time, and knowledge are commonly cited as reasons for non-adherence to recommended standards of care. The Chronic Care Model offers an approach to healthcare organizations for chronic disease management. The model consists of six elements that work together to empower both providers and patients to have more productive interactions: the community, the health system itself, self-management support, delivery system design, decision support, and clinical information systems. The model and its elements may offer a framework through which healthcare organizations can adapt to support, educate, and empower providers and patients in the management of excess weight and obesity. Successful management of excess weight will reduce morbidity and mortality of many chronic conditions. Purpose. The purpose of this review is to synthesize existing research on the effectiveness of the Chronic Care Model and its elements as they relate to weight management and behaviors associated with maintaining a healthy weight. Methods: A narrative review of the literature between November 1998 and November 2008 was conducted. The review focused on clinical trials, systematic reviews, and reports related to the chronic care model or its elements and weight management, physical activity, nutrition, or diabetes. Fifty-nine articles are included in the review. Results. This review highlights the use of the Chronic Care Model and its elements that can result in improved quality of care and clinical outcomes related to weight management, physical activity, nutrition, and diabetes. Conclusions. Healthcare organizations can use the Chronic Care Model framework to implement changes within their systems to successfully address overweight and obesity in their patient populations. Specific recommendations for operationalizing the Chronic Care Model elements for weight management are presented.^

BIOMEDICAL LANGUAGE UNDERSTANDING AND EXTRACTION (BLUE-TEXT): A MINIMAL SYNTACTIC, SEMANTIC METHOD

Clinical text understanding (CTU) is of interest to health informatics because critical clinical information frequently represented as unconstrained text in electronic health records are extensively used by human experts to guide clinical practice, decision making, and to document delivery of care, but are largely unusable by information systems for queries and computations. Recent initiatives advocating for translational research call for generation of technologies that can integrate structured clinical data with unstructured data, provide a unified interface to all data, and contextualize clinical information for reuse in multidisciplinary and collaborative environment envisioned by CTSA program. This implies that technologies for the processing and interpretation of clinical text should be evaluated not only in terms of their validity and reliability in their intended environment, but also in light of their interoperability, and ability to support information integration and contextualization in a distributed and dynamic environment. This vision adds a new layer of information representation requirements that needs to be accounted for when conceptualizing implementation or acquisition of clinical text processing tools and technologies for multidisciplinary research. On the other hand, electronic health records frequently contain unconstrained clinical text with high variability in use of terms and documentation practices, and without commitmentto grammatical or syntactic structure of the language (e.g. Triage notes, physician and nurse notes, chief complaints, etc). This hinders performance of natural language processing technologies which typically rely heavily on the syntax of language and grammatical structure of the text. This document introduces our method to transform unconstrained clinical text found in electronic health information systems to a formal (computationally understandable) representation that is suitable for querying, integration, contextualization and reuse, and is resilient to the grammatical and syntactic irregularities of the clinical text. We present our design rationale, method, and results of evaluation in processing chief complaints and triage notes from 8 different emergency departments in Houston Texas. At the end, we will discuss significance of our contribution in enabling use of clinical text in a practical bio-surveillance setting.

Implementación del modelo RIM de HL7 v3 en orientación a objetos y su uso en procesos de interoperabilidad semántica

El trabajo ha sido realizado dentro del marco de los proyectos EURECA (Enabling information re-Use by linking clinical REsearch and Care) e INTEGRATE (Integrative Cancer Research Through Innovative Biomedical Infrastructures), en los que colabora el Grupo de Informática Biomédica de la UPM junto a otras universidades e instituciones sanitarias europeas. En ambos proyectos se desarrollan servicios e infraestructuras con el objetivo principal de almacenar información clínica, procedente de fuentes diversas (como por ejemplo de historiales clínicos electrónicos de hospitales, de ensayos clínicos o artículos de investigación biomédica), de una forma común y fácilmente accesible y consultable para facilitar al máximo la investigación de estos ámbitos, de manera colaborativa entre instituciones. Esta es la idea principal de la interoperabilidad semántica en la que se concentran ambos proyectos, siendo clave para el correcto funcionamiento del software del que se componen. El intercambio de datos con un modelo de representación compartido, común y sin ambigüedades, en el que cada concepto, término o dato clínico tendrá una única forma de representación. Lo cual permite la inferencia de conocimiento, y encaja perfectamente en el contexto de la investigación médica. En concreto, la herramienta a desarrollar en este trabajo también está orientada a la idea de maximizar la interoperabilidad semántica, pues se ocupa de la carga de información clínica con un formato estandarizado en un modelo común de almacenamiento de datos, implementado en bases de datos relacionales. El trabajo ha sido desarrollado en el periodo comprendido entre el 3 de Febrero y el 6 de Junio de 2014. Se ha seguido un ciclo de vida en cascada para la organización del trabajo realizado en las tareas de las que se compone el proyecto, de modo que una fase no puede iniciarse sin que se haya terminado, revisado y aceptado la fase anterior. Exceptuando la tarea de documentación del trabajo (para la elaboración de esta memoria), que se ha desarrollado paralelamente a todas las demás. ----ABSTRACT--- The project has been developed during the second semester of the 2013/2014 academic year. This Project has been done inside EURECA and INTEGRATE European biomedical research projects, where the GIB (Biomedical Informatics Group) of the UPM works as a partner. Both projects aim is to develop platforms and services with the main goal of storing clinical information (e.g. information from hospital electronic health records (EHRs), clinical trials or research articles) in a common way and easy to access and query, in order to support medical research. The whole software environment of these projects is based on the idea of semantic interoperability, which means the ability of computer systems to exchange data with unambiguous and shared meaning. This idea allows knowledge inference, which fits perfectly in medical research context. The tool to develop in this project is also "semantic operability-oriented". Its purpose is to store standardized clinical information in a common data model, implemented in relational databases. The project has been performed during the period between February 3rd and June 6th, of 2014. It has followed a "Waterfall model" of software development, in which progress is seen as flowing steadily downwards through its phases. Each phase starts when its previous phase has been completed and reviewed. The task of documenting the project‟s work is an exception; it has been performed in a parallel way to the rest of the tasks.

Business model for healthcare interoperability services

En la situación actual donde los sistemas TI sanitarios son diversos con modelos que van desde soluciones predominantes, adoptadas y creadas por grandes organizaciones, hasta soluciones a medida desarrolladas por cualquier empresa de la competencia para satisfacer necesidades concretas. Todos estos sistemas se encuentran bajo similares presiones financieras, no sólo de las condiciones económicas mundiales actuales y el aumento de los costes sanitarios, sino también bajo las presiones de una población que ha adoptado los avances tecnológicos actuales, y demanda una atención sanitaria más personalizable a la altura de esos avances tecnológicos que disfruta en otros ámbitos. El objeto es desarrollar un modelo de negocio orientado al soporte del intercambio de información en el ámbito clínico. El objetivo de este modelo de negocio es aumentar la competitividad dentro de este sector sin la necesidad de recurrir a expertos en estándares, proporcionando perfiles técnicos cualificados menos costosos con la ayuda de herramientas que simplifiquen el uso de los estándares de interoperabilidad. Se hará uso de especificaciones abiertas ya existentes como FHIR, que publica documentación y tutoriales bajo licencias abiertas. La principal ventaja que nos encontramos es que ésta especificación presenta un giro en la concepción actual de la disposición de información clínica, vista hasta ahora como especial por el requerimiento de estándares más complejos que solucionen cualquier caso por específico que sea. Ésta especificación permite hacer uso de la información clínica a través de tecnologías web actuales (HTTP, HTML, OAuth2, JSON, XML) que todo el mundo puede usar sin un entrenamiento particular para crear y consumir esta información. Partiendo por tanto de un mercado con una integración de la información casi inexistente, comparada con otros entornos actuales, hará que el gasto en integración clínica aumente dramáticamente, dejando atrás los desafíos técnicos cuyo gasto retrocederá a un segundo plano. El gasto se centrará en las expectativas de lo que se puede obtener en la tendencia actual de la personalización de los datos clínicos de los pacientes, con acceso a los registros de instituciones junto con datos ‘sociales/móviles/big data’.---ABSTRACT---In the current situation IT health systems are diverse, with models varying from predominant solutions adopted and created by large organizations, to ad-hoc solutions developed by any company to meet specific needs. However, all these systems are under similar financial pressures, not only from current global economic conditions and increased health care costs, but also under pressure from a population that has embraced the current technological advances, and demand a more personalized health care, up to those enjoyed by technological advances in other areas. The purpose of this thesis is to develop a business model aimed at the provision of information exchange within the clinical domain. It is intended to increase competitiveness in the health IT sector without the need for experts in standards, providing qualified technical profiles less expensively with the help of tools that simplify the use of interoperability standards. Open specifications, like FHIR, will be used in order to enable interoperability between systems. The main advantage found within FHIR is that introduces a shift in the current conception of available clinical information. So far seen, the clinical information domain IT systems, as a special requirement for more complex standards that address any specific case. This specification allows the use of clinical information through existing web technologies (HTTP, HTML, OAuth2, JSON and XML), which everyone can use with no particular training to create and consume this information. The current situation in the sector is that the integration of information is almost nonexistent, compared to current trends. Spending in IT health systems will increase dramatically within clinical integration for the next years, leaving the technical challenges whose costs will recede into the background. The investment on this area will focus on the expectations of what can be obtained in the current trend of personalization of clinical data of patients with access to records of institutions with ‘social /mobile /big data’.

OrCGDB: a database of genes involved in oral cancer

The Oral Cancer Gene Database (OrCGDB; http://www.tumor-gene.org/Oral/oral.html) was developed to provide the biomedical community with easy access to the latest information on the genes involved in oral cancer. The information is stored in a relational database and accessed through a WWW interface. The OrCGDB is organized by gene name, which is linked to information describing properties of the gene. This information is stored as a collection of findings (‘facts’) that are entered by the database curator in a semi-structured format from information in primary publications using a WWW interface. These facts include causes of oncogenic activation, chromosomal localization of the gene, mutations associated with the gene, the biochemical identity and activity of the gene product, synonyms for the gene name and a variety of clinical information. Each fact is associated with a MEDLINE citation. The user can search the OrCGDB by gene name or by entering a textword. The OrCGDB is part of a larger WWW-based tumor gene database and represents a new approach to catalog and display the research literature.

Análisis del uso de métodos de similitud léxica con conocimiento semántico superficial para mapear la información de enfermería en español

Uno de los problemas actuales en el dominio de la salud es reutilizar y compartir la información clínica entre profesionales, ya que ésta se encuentra escrita usando terminologías específicas. Una posible solución es usar un recurso de conocimiento común sobre el que mapear la información existente. Nuestro objetivo es comprobar si la adición de conocimiento semántico superficial puede mejorar los mapeados establecidos. Para ello experimentamos con un conjunto de etiquetas de NANDA-I y con un conjunto de descripciones de SNOMED-CT en castellano. Los resultados obtenidos en los experimentos muestran que la inclusión de conocimiento semántico superficial mejora significativamente el mapeado léxico entre los dos recursos estudiados.

Evolução da tiroidite de hashimoto

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Eficiência do metotrexato na artrite psoriática

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

A feasibility study of email communication between the patient's family and the specialist burns team

We investigated whether the parents of burns patients could capture suitable clinical images with a digital camera and add the necessary text information to enable the paediatric burns team to provide follow-up care via email. Four families were involved in the study, each of whom sent regular email consultations for six months. The results were very encouraging. The burns team felt confident that the clinical information in 30 of the 32 email messages (94%) they received was accurate, although in I I of these 30 cases (37%) they stated that there was room for improvement (the quality was nonetheless adequate for clinical decision making). The study also showed that low-resolution images (average size 37 kByte) were satisfactory for diagnosis. Families were able to participate in the service without intensive training and support. The user survey showed that all four families found it easy and convenient to take the digital photographs and to participate in the study. The results suggest that the technique has potential as a low-cost telemedicine service in burns follow-up, and that it requires only modest investment in equipment, training and support.

Quantifying short-term dynamics of Parkinson's disease using self-reported symptom data from an internet social network

Background: Parkinson’s disease (PD) is an incurable neurological disease with approximately 0.3% prevalence. The hallmark symptom is gradual movement deterioration. Current scientific consensus about disease progression holds that symptoms will worsen smoothly over time unless treated. Accurate information about symptom dynamics is of critical importance to patients, caregivers, and the scientific community for the design of new treatments, clinical decision making, and individual disease management. Long-term studies characterize the typical time course of the disease as an early linear progression gradually reaching a plateau in later stages. However, symptom dynamics over durations of days to weeks remains unquantified. Currently, there is a scarcity of objective clinical information about symptom dynamics at intervals shorter than 3 months stretching over several years, but Internet-based patient self-report platforms may change this. Objective: To assess the clinical value of online self-reported PD symptom data recorded by users of the health-focused Internet social research platform PatientsLikeMe (PLM), in which patients quantify their symptoms on a regular basis on a subset of the Unified Parkinson’s Disease Ratings Scale (UPDRS). By analyzing this data, we aim for a scientific window on the nature of symptom dynamics for assessment intervals shorter than 3 months over durations of several years. Methods: Online self-reported data was validated against the gold standard Parkinson’s Disease Data and Organizing Center (PD-DOC) database, containing clinical symptom data at intervals greater than 3 months. The data were compared visually using quantile-quantile plots, and numerically using the Kolmogorov-Smirnov test. By using a simple piecewise linear trend estimation algorithm, the PLM data was smoothed to separate random fluctuations from continuous symptom dynamics. Subtracting the trends from the original data revealed random fluctuations in symptom severity. The average magnitude of fluctuations versus time since diagnosis was modeled by using a gamma generalized linear model. Results: Distributions of ages at diagnosis and UPDRS in the PLM and PD-DOC databases were broadly consistent. The PLM patients were systematically younger than the PD-DOC patients and showed increased symptom severity in the PD off state. The average fluctuation in symptoms (UPDRS Parts I and II) was 2.6 points at the time of diagnosis, rising to 5.9 points 16 years after diagnosis. This fluctuation exceeds the estimated minimal and moderate clinically important differences, respectively. Not all patients conformed to the current clinical picture of gradual, smooth changes: many patients had regimes where symptom severity varied in an unpredictable manner, or underwent large rapid changes in an otherwise more stable progression. Conclusions: This information about short-term PD symptom dynamics contributes new scientific understanding about the disease progression, currently very costly to obtain without self-administered Internet-based reporting. This understanding should have implications for the optimization of clinical trials into new treatments and for the choice of treatment decision timescales.

Discovering the preferences of physicians with regards to rank-ordered medical documents

The practice of evidence-based medicine involves consulting documents from repositories such as Scopus, PubMed, or the Cochrane Library. The most common approach for presenting retrieved documents is in the form of a list, with the assumption that the higher a document is on a list, the more relevant it is. Despite this list-based presentation, it is seldom studied how physicians perceive the importance of the order of documents presented in a list. This paper describes an empirical study that elicited and modeled physicians' preferences with regard to list-based results. Preferences were analyzed using a GRIP method that relies on pairwise comparisons of selected subsets of possible rank-ordered lists composed of 3 documents. The results allow us to draw conclusions regarding physicians' attitudes towards the importance of having documents ranked correctly on a result list, versus the importance of retrieving relevant but misplaced documents. Our findings should help developers of clinical information retrieval applications when deciding how retrieved documents should be presented and how performance of the application should be assessed. © 2012 Springer-Verlag Berlin Heidelberg.