An Information System for Epidemiology based on a Computer-Based Medical Record

A new way is presented to build an information system addressed to problems in epidemiology. Based on our analysis of current and future requirements, a system is proposed which allows for collection, organization and distribution of data within a computer network. In this application, two broad communities of users – physicians and epidemiologists – can be identified, each with their own perspectives and goals. The different requirements of each community lead us to a client-service centered architecture which provides the functionality requirements of the two groups. The resulting physician workstation provides help for recording and querying medical information about patients and from a pharmacological database. All information is classified and coded in order to be retrieved for pharmaco-economic studies. The service center receives information from physician workstations and permits organizations that are in charge of statistical studies to work with “real” data recorded during patient encounters. This leads to a new approach in epidemiology. Studies can be carried out with a more efficient data acquisition. For modelling the information system, we use an object-oriented approach. We have observed that the object-oriented representation, particularly its concepts of generalization, aggregation and encapsulation, are very usable for our problem.

The Rhône-Alpes Health Platform

Objectives: The purpose of this workis to develop a health information platform connecting most health facilities in the Rhône-Alpes region. The health platform called SIS-RA is used through a Web interface. An iconic interface is dedicated to the platform and presents information in a unique way for all users.

Methods: Newtechniques have been used to develop this platform which will be used by a great number of Rhône-Alpes doctors in the future. We chose a user-centered design which takes into account doctors’ requirements (hospital and GP). We also consider that no system has to be rebuilt, but a direct connection to the legacysystems should be provided.

Results: The platform permits fast and more appropriate medical decisions than those made without this information system. The iconic interface presents all medical documents in a uniform way. Currently, 11 healthcare facilities and 15 community health networks are connected to SIS-RA sharing more than 60,000 records with 1.2 million indexed items. 3200 doctors use the system.

Conclusion: The platform is approved by French supervision authorities (regional hospitals association (ARH)), regional practitioners union (URML) and Rhônes-Alpes region administration and is known as the official shared health record.

Febrile neutropenia in cats treated with chemotherapy

The purpose of this study was to describe the clinical presentation, potential causative agents, treatment and outcome of febrile neutropenia (FN) in chemotherapy-treated cats. Medical records from eight institutions were retrospectively reviewed. A total of 22 FN events in 20 cats were evaluated. Lymphoma was the most common cancer diagnosis; lomustine and vinca alkaloids were the most frequently implicated causative agents. Presenting clinical signs included decreased appetite, lethargy, vomiting and diarrhoea. Median body temperature and absolute neutrophil count at presentation were 104.1 °F; 40 °C (range: 103.1-105.1 °F; 39.5-40.6 °C) and 246 mL^-1 (range: 0-1600 mL^-1 ), respectively. Median number of days between chemotherapy administration and FN onset was 5 (range: 4-25 days). All but one cat were treated with intravenous fluids and broad spectrum antibiotics. Fevers resolved in all cases and absolute neutrophil counts returned to normal in 19 cats. Clinical presentation of cats with FN appears similar to that of dogs.

Phase II study of oral docetaxel and cyclosporine in canine epithelial cancer

The goal of the current study was to determine the efficacy of oral docetaxel in combination with cyclosporine in the treatment of canine epithelial cancer. Requirements for eligibility were histological confirmation of epithelial neoplasia, measurable disease, no chemotherapy treatment within 2 weeks, and a life expectancy of ≥ 3 months. Fifty-one dogs were enrolled. All dogs received 1.625 mg kg(-1) of docetaxel with 5 mg kg(-1) of cyclosporine (DT/CSA) by gavage. Ten dogs had progressive disease at 2 weeks, one dog died, and one dog was withdrawn from the study. Thirty-nine dogs were given a second dose of DT/CSA, three each receiving a third or fourth dose. Eight dogs had a dose reduction (1.5 mg kg(-1)) and six dogs had treatment delays primarily for gastrointestinal toxicity. The overall response rate was 16.7% (8/48 had a partial response there were no complete responses). The highest response rate was seen in dogs with oral squamous cell carcinoma (50%; 6/12).

Evaluation of dexamethasone as a chemoprotectant for CCNU-induced bone marrow suppression in dogs

In mice and people, administering corticosteroids before chemotherapy can reduce the severity of myelosuppression without reducing antitumour effects. This study investigated whether pretreatment with dexamethasone would reduce the incidence of grade 4 neutropenia in dogs receiving CCNU. Twenty-five dogs received dexamethasone [0.1 mg kg(-1) per os (PO) every 12 h] for 5 days and on the sixth day received CCNU (90 mg m(-2) PO). Historical dogs (n = 67) received CCNU alone (90 mg m(-2) PO). Forty-five percent of historical dogs had grade 4 neutropenia, while 64% of dogs pretreated with dexamethasone had grade 4 neutropenia (P = 0.16). Dexamethasone plasma levels were quantified by enzyme-linked immunosorbent assay in three healthy dogs. Peak plasma concentrations after a single oral 0.1-mg kg(-1) dose were <80 ng mL(-1), the minimum level associated with chemoprotective effects of dexamethasone in people. Pretreatment with dexamethasone did not reduce the incidence of grade 4 neutropenia in dogs receiving CCNU.

Combination of CCNU and DTIC chemotherapy for treatment of resistant lymphoma in dogs

BACKGROUND

Pleotropic-glycoprotein (P-gp)-mediated resistance is the usual cause of relapse in dogs with lymphoma. 1-(2-chloroethyl)3-cyclohexyl-1-nitrosurea (CCNU) and 5-(3,3-dimethyl-1-triazeno)-imidazole-4-carboxamide (DTIC) are alkylating agents that are not affected by P-gp and lack cross-resistance to each other. A combination protocol offers the advantage of improved summation dose and synergistic activity.

HYPOTHESIS

A combination of CCNU and DTIC that is well tolerated can be used to treat dogs with lymphoma that developed resistance or failed to respond to previously administered chemotherapy.

ANIMALS

Fifty-seven dogs with lymphoma that were resistant to treatment with standard chemotherapy (L-CHOP; L-asparaginase, cyclophosphamide, doxorubicin, vincristine, prednisone).

METHODS

Prospective phase I and II trials were performed. CCNU was given PO immediately before a 5-h IV infusion of DTIC. Concurrent antiemetics and prophylactic antibiotics were used. Treatments were administered every 4 weeks.

RESULTS

Based on the results of 8 dogs in the phase I study, CCNU at 40 mg/m(2) PO combined with DTIC at 600 mg/m(2) IV was used to treat 57 dogs with resistant lymphoma. Thirteen (23%) dogs had a complete response (CR) for a median of 83 days and 7 (12%) had a partial response for a median of 25 days. The median L-CHOP CR duration of the dogs that did not respond to CCNU-DTIC was significantly longer than that of the dogs that did achieve remission with CCNU-DTIC (225 days versus 92 days, P= .02). The principal toxic event was neutropenia; the median neutrophil count 7 days after treatment was 1,275 cells/microL. Increases in alanine transaminase activity, possibly associated with hepatotoxicity, were detected in 7 dogs.

CONCLUSIONS AND CLINICAL IMPORTANCE

A combination of CCNU and DTIC can be an effective option to rescue dogs with resistant lymphoma.

The Rhône-Alpes health platform

OBJECTIVES

The purpose of this work is to develop a health information platform connecting most health facilities in the Rhône-Alpes region. The health platform called SIS-RA is used through a Web interface. An iconic interface is dedicated to the platform and presents information in a unique way for all users.

METHODS

New techniques have been used to develop this platform which will be used by a great number of Rhône-Alpes doctors in the future. We chose a usercentered design which takes into account doctors' requirements (hospital and GP). We also consider that no system has to be rebuilt, but a direct connection to the legacy systems should be provided.

RESULTS

The platform permits fast and more appropriate medical decisions than those made without this information system. The iconic interface presents all medical documents in a uniform way. Currently, 11 healthcare facilities and 15 community health networks are connected to SIS-RA sharing more than 60,000 records with 1.2 million indexed items. 3200 doctors use the system.

CONCLUSION

The platform is approved by French supervision authorities (regional hospitals association (ARH)), regional practitioners union (URML) and Rhônes-Alpes region administration and is known as the official shared health record.

Medical records and electronic documents: a proposal

This article presents a global view of our proposal for a medical information system of the future. This information system focuses on patient medical records management. As most of the existing systems, it proposes to store information from patient records in a database. But records capture is different: we propose to use weakly-structured documents. Such documents contain paragraphs with some specific constraints represented by XML tags. The end-user writes new information under the form of weakly-structured documents. An internal system translates theses documents into new data for the internal database. Such a document-based user interface provides much more freedom to the end-user, and certainly reduces the distance between the physicians' way of working and the capture system.

A four-dimensional approach to medical image retrieval

Image retrieval is faced with different problems. Few proposed solutions consider the heterogeneity of user competence (e.g. physicians, researchers, students, etc.) and the necessity of a high expressive power for medical image description. This paper presents a solution designed for medical imaging retrieval. It consists of providing a four-dimensional approach able to integrate different views of the medical image, to deal with complex medical queries. Via use of the Spatial Knowledge Model, we propose hybrid (textual and visual) and customizable interfaces, appropriate for non-computer scientist users. Our prototype, accessible through the Web, has been tested by a group of medical students and physicians and gives very satisfactory results.

The electronic medical record: using documents for information capture

This work concerns the management of electronic medical records. Classical systems based on databases do not satisfy end users, as the provided capture forms are never completely adapted to the patient case and to the physician's way of working. Electronic documents proved to be a better user interface paradigm, but still do not provide satisfying querying performance. Our work concerns the use of semi-structured documents as a user interface for a database-based system. The captured documents are analyzed so that information is extracted and used to fill in a database. We illustrate our proposition with the prototype we have developed and a short example.

A Four-dimensional Approach to Medical Image Retrieval

Image retrieval is faced with different problems. Few proposed solutions consider the heterogeneity of user competence (e.g. physicians, researchers, students, etc.) and the necessity of a high expressive power for medical image description. This paper presents a solution designed for medical imaging retrieval. It consists of providing a four-dimensional approach able to integrate different views of the medical image, to deal with complex medical queries. Via use of the Spatial Knowledge Model, we propose hybrid (textual and visual) and customizable interfaces, appropriate for non-computer scientist users. Our prototype, accessible through the Web, has been tested by a group of medical students and physicians and gives very satisfactory results.

Nutritional status of haemodialysis patients: a French national cooperative study. French Study Group for Nutrition in Dialysis

BACKGROUND

Despite the severity and the prognosis value of undernutrition in haemodialysed patients, no large study is available as yet in Europe. Hence, this French National Cooperative Study aimed to determine the prevalence of undernutrition and its relationship to dialysis efficacy.

METHODS

Nutritional status was determined in 7123 patients (i.e. one-third of the French haemodialysis population) using body mass index (BMI), predialysis haemoglobin, albumin, pre-albumin, cholesterol, and also normalized protein catabolic rate (nPCR) and lean body mass (LBM) calculated from pre- and postdialysis urea and creatinine. Dialysis treatment was estimated from weekly dialysis time and KtV determination.

RESULTS

Dialysis time was 12.4+/-2.7 h/week and KtV 1.36+/-0.36. BMI was below 20 kg/m2 in 24% and the observed/expected LBM ratio below 90% in 62%. Albumin, pre-albumin and nPCR were below the high-risk thresholds of 35 g/l, 300 mg/l and 1g/kg/day in 20%, 36% and 35% of patients, respectively. Pre-albumin was the most representative nutritional parameter. Albumin, pre-albumin and LBM correlated with nPCR. A dialysis time above 12 h/week was associated with higher BMI, albumin, pre-albumin and LBM. LBM was higher in patients with a KtV value >1.1.

CONCLUSION

This study showed life-threatening undernutrition in 20-36% of the studied population, according to nutritional parameters. Protein intake (estimated by nPCR) and dialysis efficacy (estimated by dialysis time and KtV) appeared to be major determinants of nutritional status in this population.

A hypermedia-based medical records management system

This article presents a new way to manage computerized medical records, based on a totally-hypermedia system. As a matter of fact, the classical use of a database limits the necessary variability of the medical record, in function of both the patient profile and the care practitioner habits. The system we propose is based on a hospital Intranet, and on the XML language. This language allows the definition of semantic tags in hyperdocuments, and thus information retrieval is ensured through semantic tags indexation.

A generic model for Internet-accessed databases in epidemiology: a nutritional application

The Web technology has made the exchange of information among heterogeneous platforms possible with no added cost to end-users. Adding to this, it made it possible to access databases residing on servers in different geographic locations giving thus conceptors and programmers the possibility of making distributed applications with a fraction of the time needed before. This technology is therefore very well suited to medical applications which are normally multi-user, multiplatform, and data-intensive. In this paper, we present an application for epidemiological studies based on the Web technology and the reuse of common concepts in epidemiology to produce a generic model that can be parameterisable by the end-user to suit the needs of his study. This model is then applied to develop an application to optimise the collection and processing of nutritional data for a nation-wide epidemiological study concerning renal failure patients.

[Proposals for a system of managing medical information]

Various systems are being used for managing medical information. They have several shortcomings. Among these, one can quote: -they do not overcome the complex medical terminology and its diversity; -they do not use a common medical language -there is no easy communication between the softwares used -and so on The proposed system takes into account the multiplicity of information sources within a hospital and the need for individual decision-making from care providers.

An information system for epidemiology based on a computer-based medical record

A new way is presented to build an information system addressed to problems in epidemiology. Based on our analysis of current and future requirements, a system is proposed which allows for collection, organization and distribution of data within a computer network. In this application, two broad communities of users-physicians and epidemiologists-can be identified, each with their own perspectives and goals. The different requirements of each community lead us to a client-service centered architecture which provides the functionality requirements of the two groups. The resulting physician workstation provides help for recording and querying medical information about patients and from a pharmacological database. All information is classified and coded in order to be retrieved for pharmaco-economic studies. The service center receives information from physician workstations and permits organizations that are in charge of statistical studies to work with "real" data recorded during patient encounters. This leads to a new approach in epidemiology. Studies can be carried out with a more efficient data acquisition. For modelling the information system, we use an object-oriented approach. We have observed that the object-oriented representation, particularly its concepts of generalization, aggregation and encapsulation, are very usable for our problem.