bluuebunny/crossref_metadata_2025 huggingface dataset:
On a Hybrid Method in Dose Finding Studies
Authors: Pinheiro J. C. , Branson M. , Bretz F.
Published: March 2018

Objectives:
Combination of multiple testing and modeling techniques in dose-response studies. Use of hypotheses tests to assess the significance of the dose-response signal associated with a given candidate dose-response model. Estimation of target dose(s) following the previous model selection step. Illustration of the method with a real data example.

Methods:
We assume a set of candidate models potentially reflecting the data generating process. The appropriateness of each individual model is evaluated in terms of contrast tests, where each set of contrast weights describes a specific dose-response shape. Optimum contrast weights are computed, which maxi-mize the non-centrality parameters associated with the contrast tests. A reference set of appropriate candidate models is obtained while controlling the familywise error rate. A single model is then selected from this reference set using standard model selection criteria. The final step is devoted to dose finding by applying inverse regression techniques. This is illustrated for estimating the minimum effective dose.

Results:
The method is as powerful as competing standard dose-response tests to detect an overall dose-related trend. In addition, the possibility is given to estimate one or more target doses of interest. The analysis of a real data example confirms the advantages of the proposed hybrid method.

Conclusions:
Combining multiple testing and modeling techniques leads to a powerful tool, which uses the advantages of both approaches: Rigid error control at the significance testing step and flexibility at the dose estimation step. The method can be extended to handle more general linear models including covariates and factorial treatment structures.
A Bayesian Approach to Estimate and Validate the False Negative Fraction in a Two-stage Multiple Screening Test
Authors: Ranyimbo A. O. , Held L.
Published: March 2018

Objectives:
In estimating sensitivity and specificity of a diagnostic kit it is imperative that all study subjects are verified via a gold standard procedure. However the application of such a procedure to all the study subjects may not be feasible due to associated cost, risk and invasiveness. As a result only a part of the study subjects receive the definitive assessment. The accuracy of a diagnostic kit can also be expressed in terms of its error rates. Our first objective is to estimate the false negative fraction (FNF) under partial verification in a particular case of a two-stage multiple screening test using a beta-binomial model and a Bayesian logistic model. The second objective is to validate the two models in order to determine which fits the data better.

Methods:
We estimate the FNF from the above mentioned models using Bayesian approach. The validation of the models is based on their out-of-sample predictive capabilities.

Results:
For the bowel cancer data that was used in this study we found the median posterior estimate of the FNF, based on the beta-binomial model, to be 26.4% (95% credible interval: 0.123-0.650). The corresponding estimate based on the Bayesian logistic model was 23.3% (95% credible interval: 0.124-0.375). Validation results showed that the beta-binomial model gave slightly better predictions compared to the Bayesian logistic model.

Conclusions:
Estimation of the FNF can be done by adopting the Bayesian approach. Models fitted can be validated by comparing their performance in terms of their out-of-sample predicitve potential.
Prospective Molecular Epidemiological Study on Transmission of Pulmonary Tuberculosis and Migration (MuT Study)
Authors: Becher H. , Dreweck C. , Haas W. , Richter E. , Niemann S. , Junghanss T. , Bischof U.
Published: March 2018

Introduction:
In Western Europe prevalence and incidence of tuberculosis in the indigenous population is declining and TB in migrants from high prevalence countries is becoming a major issue of TB control. Resulting changes in transmission patterns need to be investigated to adapt control strategies. The MuT (Migration and Tuberculosis) study a co-operation among federal and local public health services (ÖDG), the National Surveillance Center (RKI) and the University has been established in Baden-Wuerttemberg to address these issues.

Objectives:
The goal of this ongoing study is to determine the transmission dynamics of TB in Baden-Wuerttemberg. Here, we present the first set of data on TB cases and their contacts and discuss strategies to overcome arising difficulties.

Methods:
Prospective data collection of culture positive pulmonary tuberculosis cases and their contacts. Analysis of (1) routine data, (2) spatial data, (3) social interaction data, (4) molecular typing data, and (5) observational data of the implementation phase.

Results:
The study demonstrates the capability of the study consortium to identify clusters. It provides valuable insights into current case detection and case management procedures and shows ways to improve. A set of factors has been identified that (a) facilitate and (b) discourage study participation.

Conclusion:
Collaboration among federal and local public health services (ÖGD), National Surveillance Center (RKI) and the University is a promising approach to investigate and improve TB control. This model has potentials for other infectious disease control.
Interaction Effects and Population-attributable Risks for Smoking and Alcohol on Laryngeal Cancer and Its Subsites
Authors: Dietz A. , Becher H. , Ramroth H.
Published: March 2018

Objectives:
To assess the joint effect of smoking and alcohol consumption on laryngeal risk on tumor subsites.

Methods:
Population-based case-control study in South-West Germany with 257 histologically confirmed cases (236 males, 21 females), age 37 to 80 years, and 769 population controls (702 males, 67 females), 1:3 frequency matched by age and sex.

Results:
Half of the tumors (50.6%) were glottic or subglottic, 17.5% were supraglottic. Due to advanced stage, the subsite of 31.9% of the tumors could not be determined clearly. There is a strong increase in risk with increasing tobacco consumption with an odds ratio (OR) of 59.8 (95% confidence interval (CI) 21.3-167.3) for heavy smoking (>80 packyears (py)), all cases combined. In comparison to current smokers, cancer risk is reduced for ex-smoking (>2 years) OR=0.36, 95% CI 0.24-0.53. The risks were higher for supraglottic than for glottic and sub-glottic tumors. The effect of alcohol is not as strong. A significantly increased odds ratio of 2.0, 95% CI (1.0-3.9) results for 75-100 g ethanol/day only for glottic and subglottic tumors. The OR rises from 2.2, 95% CI (1.1-4.3) for 100-150 g ethanol/day to 4.3, 95% CI (1.4-13.2) for more than 150 g ethanol/day (all models adjusted for education). The joint effect of smoking and alcohol results appears sub-multiplicative but super-additive. Almost 90% of the tumors can be attributed to both factors.

Conclusion:
Contrary to earlier investigations we observed a sub-multiplicative effect of smoking and alcohol. The risk for persons with both high alcohol and tobacco consumption is extremely high which indicates the importance of intervention.
Different Methods to Calculate Effect Estimates in Cross-sectional Studies
Authors: Taeger D. , Wellmann J. , Keil U. , Behrens T.
Published: March 2018

Objectives:
According to results from the epidemiological literature, it can be expected that the prevalence odds ratio (POR) and the prevalence ratio (PR) differ with increasing disease prevalence. We illustrate different concepts to calculate these effect measures in cross-sectional studies and discuss their advantages and weaknesses, using actual data from the ISAAC Phase III cross-sectional survey in Münster, Germany.

Methods:
We analyzed data on the association between self-reported traffic density and wheeze and asthma by means of the POR, obtained from a logistic regression, and the PR, which was estimated from a log-linear binomial model and from different variants of a Poisson regression.

Results:
The analysis based on the less frequent disease, i.e. asthma with an overall prevalence of 7.8%, yielded similar results for all estimates. When wheezing with a prevalence of 17.5% was analyzed, the POR produced the highest estimates with the widest confidence intervals. While the point estimates were similar in the log-binomial model and Poisson regression, the latter showed wider confidence intervals. When we calculated the Poisson regression with robust variances, confidence intervals narrowed.

Conclusions:
Since cross-sectional studies often deal with frequent diseases, we encourage analyzing cross-sectional data based on log-linear binomial models, which is the ‘natural method’ for estimating prevalence ratios. If algorithms fail to converge, a useful alternative is to define appropriate starting values or, if models still do not converge, to calculate a Poisson regression with robust estimates to control for overestimation of errors in the binomial data.
Analysis of Proportions from Clustered Data with Missing Observations in a Matched-pair Design
Authors: Nevalainen J. , Schwenke C.
Published: March 2018

Objectives:
Typically, methods for the estimation of differences in proportions from clustered data are based on complete cases with no missing information [1, 2]. In this paper we propose an extension to the method of Rao and Scott [3] and Obuchowski [2] to allow for the explicit computation of the variance of the estimator for the difference in presence of incomplete cases.

Methods:
We divided the full analysis set into a set of complete cases and a set of incomplete cases. The differences in proportions of correct diagnoses were estimated for each set by taking into consideration the clustering effect for both sets and the correlation between the procedures in the set with complete cases. Then the estimates of the two parts were combined by appropriate weights, which then allowed the explicit calculation of the variance. The performance of the extension as compared to the original method and generalized estimation equations model (GEEs) was examined by simulations.

Results:
The results of the examples suggest that the extended approach is superior to the complete-case method and is therefore appropriate when all data are to be used. In comparison to GEEs, the extended method appears to be slightly inferior, when the number of observations per patient is high, but of similar efficiency with a low number of observations per patient.

Conclusions:
With the extension of the method by Rao and Scott [3] and Obuchowski [2] we make use of all available data. Therefore, we follow the intent-to-treat principle as close as possible.
Current and Future Use of ICT for Patient Care and Management in German Acute Hospitals
Authors: Sellemann B. , Hübner U.
Published: March 2018

Objectives:
This study aimed at gaining comprehensive information on the current status of patient care and management applications used in German acute hospitals. Since the degree of ICT coverage in hospitals depends on the attitude of the key decision makers we also wanted to capture their plans and priorities and herewith try to predict future use.

Methods:
We therefore conducted a nation-wide survey including all acute hospitals in Germany in which two questionnaires were mailed to each hospital, one to the nursing managers, the other to the hospital managers.

Results:
Six hundred hospitals participated in the survey which corresponds to an overall response rate of 27.6%. Accounting (84%) was found to be the most prevalent management module. Rostering was implemented in every second hospital. For clinical applications laboratory systems ranked first (69%). Ordering systems were used in nearly every second hospital. Nineteen percent of the hospitals reported employing an electronic patient record, 7% a nursing documentation system. Ranked by their priorities ordering systems hold the first position and care planning the last position. According to their plans, hospital managers, not nursing managers, intend to introduce nursing documentation. In contrast, nursing managers favor ordering and rostering for the near future.

Conclusions:
There is still a preponderance of management-oriented systems in German hospitals, yet clinical applications, in particular those supporting communications, will gain ground. The future of documentation systems is unclear, unless they not only provide statistical data for the management but support the clinical process properly.
A Simulation Study Using Validated Prognostic Factors to Assess Expected Long-term Survival
Authors: Hasford J. , Pfirrmann M.
Published: March 2018

Objectives:
In chronic myeloid leukemia, after promising results in major cytogenetic remission (MCR), longterm survival data on imatinib treatment is of particular interest, especially in relation to former standard treatment based on interferon-alpha. However, data is still unavailable and due to high remission rates, most patients randomized to interferon-alpha in a clinical trial crossed over to imatinib. Therefore, to assess the expected long-term survival advantage with imatinib, a simulation study based on prognostic factors validated for interferon-alpha treatment was performed.

Methods:
In interferon-alpha-treated patients with intermediate-risk and low-risk according to the established New CML score, survival probabilities of patients with MCR were significantly higher than those of patients without MCR. Three samples with simulated survival data for imatinib-treated intermediate-risk patients were constituted by randomly drawing varying percentages of their survival times from interferon-alpha-treated intermediate-risk patients with MCR and the remaining data from intermediate-risk patients without MCR. The same procedure was applied to low-risk patients.

Results:
The 10-year survival probabilities of interferon-alpha-treated intermediate-risk and low-risk patients were 0.22 and 0.37. In the simulated samples, when 80%, 65%, and 50% of survival times were as favorable as for interferon-alpha-treated patients with MCR, respectively, the corresponding survival probabilities were 0.43 and 0.57, 0.36 and 0.49, and 0.30 and 0.42.

Conclusions:
In all simulation samples, increments of survival probabilities by imatinib were predicted, although survival probabilities of patients with MCR were assumed to be lower than with interferon-alpha. Prognosticated survival advantage with imatinib is backed by increasing observation time of imatinib-treated patients in real studies.
Genetic Epidemiology in Germany
Authors: Wichmann H.-E.
Published: March 2018

Objectives:
Genetic epidemiology investigates the role of genetic factors and their interaction with environmental factors (in a broad meaning) for the occurrence of diseases in human populations. Its aim is to undest-and the influence of genetics on the development of dis-eases, their course and the clinical implications, with the final goal to improve prevention, diagnostics and therapy.

Methods:
Originally genetic epidemiology was understood as a specialized discipline with the main focus on family-based studies. The extraordinary development of genetics in the last decades – with respect of the understanding of the meaning of genes for human health, as well as by the availability of cost-effective high throughput methods in the lab, has opened enormous opportunities to study genetic factors. Now, genetic epidemiology and genetic statistics have a much broader application. In addition, access to large samples of patients or from the population is needed. This can be realized via biobanks.

Results:
Large biobanks with 500,000 or more patients or participants from the general population are being established or planned in the UK, Japan or the US. However, in Germany only two smaller activities are ongoing, KORA-gen in the south and POPGEN in the north. Possibilities to reach larger numbers, based on existing cohorts or disease networks are discussed. Ethical boundary conditions have to be taken into account, which seem to improve due to the Opinion of the German National Ethics Council on Biobanks for Research. Furthermore, the activities of the German centers for Genetic Epidemiological Methods (GEMs) as research and support units for genetic statistics and epidemiological methodology are described.

Conclusions:
Genetic epidemiology is based strongly on interdisciplinary collaboration and includes basics of genetics, elements of molecular biology to identify genes, population genetics, clinical medicine, and methodological disciplines as epidemiology, biostatistics and bioinformatics. In Germany the situation for this type of patient-based research has recently improved due to the National Genome Research Network (NGFN).
Knowledge for Medicine and Health Care
Authors: van Bemmel Jan H.
Published: March 2018

Dr. Donald A. B. Lindberg, Director of the U.S. National Library of Medicine, received an honorary doctorate from UMIT, the University for Health Sciences, Medical Informatics and Technology in Innsbruck, Tyrol. The celebration took place on September 28, 2004 at an academic event during a conference of the Austrian, German, and Swiss Societies of Medical Informatics, GMDS2004. Dr. Lindberg has been a pioneer in the field of computers in health care from the early 1960s onwards. In 1984 he became the Director of the National Library of Medicine in Bethesda, the world’s largest fully computerized biomedical library. Dr. Lind-berg has been involved in the early activities of the International Medical Informatics Association (IMIA), among others being the chair of the Organizing Committee for MEDINFO 86 in Washington D.C. He was elected the first president of the American Medical Informatics Association (AMIA), and served as an editor of Methods of Information in Medicine.
Atrial and Ventricular Myocardium Extraction Using Model-based Techniques
Authors: Fischer G. , Hanser F. , Seger M. , Hintermüller C. , Modre-Osprian R. , Trieb T. , Tilg B. , Pfeifer B.
Published: March 2018

Objectives:
This paper presents an efficient approach for extracting myocardial structures from given atrial and ventricular blood masses to enable non-invasive estimation of electrical excitation in human atria and ventricles.

Methods:
Based on given segmented atrial and ventricular blood masses, the approach constructs the myocardial structure directly, in the case that the myocardium can be detected in the volume data, or by using mean model information, in the case that the myocardium cannot be seen in the volume data due to image modalities or artefacts. The approach employs mathematical and gray-value morphology operations. Regulated by the spatial visibility of the myocardial structure in the medical image data especially the atrial myocardium needs to be estimated repeatedly using the a-priori knowledge given by the anatomy.

Results:
The approach was tested using eight patient data sets. The reconstruction process yielded satisfying results with respect to an efficient generation of a volume conductor model which is essential when trying to implement the estimation of electrical excitation in clinical application.

Conclusion:
The approach yields ventricular and atrial models that qualify for cardiac source imaging in a clinical setting.
Introducing Patient Cards in Clinical Routine: Evaluation of Two Research Projects
Authors: Demski H. , Engelbrecht R. , Birkmann C.
Published: March 2018

Objective:
Two research projects were analyzed in order to identify key factors of success and/or failure in introducing patient card-based systems in clinical routine.

Methods:
In DIABCARD an evaluation study focussing on user friendliness and user acceptance was conducted. In ByMedCard-HCPP the project’s system was validated and the timeliness of the project’s work analyzed.

Results:
User friendliness and user acceptance of the DIABCARD system were fairly high. The ByMedCard-HCPP system was complete in its major components and functionalities; introducing the ByMedCard-HCPP system in clinical routine delayed the project.

Conclusions:
A multitude of key factors of success such as utilized technologies, user involvement, and commitment of partners seems to contribute to the success and/or failure of introducing patient card-based systems in healthcare.
Standardized Documentation of Drug Recommendations in Discharge Letters
Authors: Pilz J. , Kaltschmidt J. , Ludt S. , Szecsenyi J. , Haefeli W. E. , Knaup P.
Published: March 2018

Objectives:
To analyze the necessity and potential usefulness of a computerized physician order entry (CPOE) system in supporting the writing of pharmacotherapeutic recommendations in discharge letters.

Methods:
Systematic analysis of drug recommendations in discharge letters of a hospital providing tertiary care, structured interviews with in-hospital prescribers, and focus groups with general practitioners who admit patients to this hospital.

Results:
We analyzed 1800 randomly selected discharge letters, 1205 of which contained pharmaco-therapeutic recommendations. The frequencies, structure, and quality of these recommendations varied considerably between departments. Nearly 16% of the recommendations contained both proprietary (brand) and non-proprietary names (active ingredient). Interviewed clinicians expressed interest in CPOE systems that check for contraindications and interactions between drugs, suggest cheaper products, and automatically insert active ingredients when omitted. The focus group sessions confirmed that the pharmacotherapeutic recommendations in current discharge letters do not effectively support daily clinical practice.

Conclusions:
Documenting active ingredients as well as brand names in drug therapy recommendations is currently not part of clinical practice. Computerized decision support can help to optimise the structure and communication of therapeutic information across interfaces and can be a quality factor with considerable influence on process quality, outcome quality, and costs of cooperative patient care.
Evaluation of Health-related Internet Use in Germany
Authors: Dumitru R. C. , Prokosch H.-U. , Birkmann C.
Published: March 2018

Objective:
An eHealth survey was conducted in a major Bavarian region in order to evaluate health-related Internet use in Germany.

Methods:
A specific questionnaire was developed by the authors to collect sociodemographic data as well as data on general and health-related Internet use. This questionnaire was distributed to patients visiting medical practices in the above mentioned Bavarian region.

Results:
Whereas many Internet users look for health-related information and products on the Internet, more advanced web-based techniques such as chat rooms and electronic patient records are hardly used.

Conclusions:
Although modern information technologies have the potential to enable citizens to handle their own health-related information in a self-determined and informed manner, at present the general population in Germany is hardly taking this opportunity.
The “Resident’s Dilemma”?
Authors: Gerber B. S. , Weiner S. J. , Heckerling P. S.
Published: March 2018

Objectives:
Medical residents engage in formal and informal education interactions with fellow residents during the working day, and can choose whether to spend time and effort on such interactions. Time and effort spent on such interactions can bring learning and personal satisfaction to residents, but may also delay completion of clinical work.

Methods:
Using hypothetical cases, we assessed the values and strategies of internal medicine residents at one hospital for both cooperative and non-cooperative education interactions with fellow residents. We then used these data and cellular automata models of two-person games to simulate repeated interactions between residents, and to determine which strategies resulted in greatest accrued value. We conducted sensitivity analyses on several model parameters, to test the robustness of dominant strategies to model assumptions.

Results:
Twenty-nine of the 57 residents (50.9%) valued cooperation more than non-cooperation no matter what the other resident did during the current interaction. Similarly, thirty-six residents (63.2%) endorsed an unconditional always-cooperate strategy no matter what the other resident had done during their previous interaction. In simulations, an always-cooperate strategy accrued more value (776.42 value units) than an aggregate of strategies containing non-cooperation components (675.0 value units, p = 0.052). Only when the probability of strategy errors reached 50%, or when values were re-ordered to match those of a Prisoner's Dilemma, did non-cooperation-based strategies accrue the most value.

Conclusions:
Cooperation-based values and strategies were most frequent among our residents, and dominated in simulations of repeated education interactions between them.
Development of a Bayesian Network for the Prognosis of Head Injuries using Graphical Model Selection Techniques
Authors: Sakellaropoulos G. C. , Nikiforidis G. C.
Published: March 2018

The assessment of a head-injured patient’s prognosis is a task that involves the evaluation of diverse sources of information. In this study we propose an analytical approach, using a Bayesian Network (BN), of combining the available evidence. The BN’s structure and parameters are derived by learning techniques applied to a database (600 records) of seven clinical and laboratory findings. The BN produces quantitative estimations of the prognosis after 24 hours for head-injured patients in the outpatients department. Alternative models are compared and their performance is tested against the success rate of an expert neurosurgeon.
ArchiMed: A Medical Information and Retrieval System
Authors: Wrba Th. , Duftschmid G. , Sachs P. , Gall W. , Rehnelt Ch. , Boldt G. , Premauer W. , Dorda W.
Published: March 2018

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.
Distinction between Planned and Unplanned Readmissions following Discharge from a Department of Internal Medicine
Authors: Sarasin F. P. , Bolla F. , Gaspoz J.-M. , Borst F. , Kossovsky M. P.
Published: March 2018

Readmission rate is often used as an indicator for the quality of care. However, only unplanned readmissions may have a link with substandard quality of care. We compared two databases of the Geneva University Hospitals to determine which information is needed to distinguish planned from unplanned readmissions. All patients readmitted within 42 days after a first stay in the wards of the Department of Internal Medicine were identified. One of the databases contained encoded information needed to compute DRGs. The other database consisted of full-text discharge reports, addressed to the referring physician. Encoded reports allowed the classification of 64% of the readmissions, whereas full-text reports could classify 97% of the readmissions (p <0.001). The concordance between encoded reports and full-text reports was fair (kappa = 0.40). We conclude that encoded reports alone are not sufficient to distinguish planned from unplanned readmissions and that the automation of detailed clinical databases seems promising.
Medical Record Management Systems: Criticisms and New Perspectives
Authors: Frénot S. , Laforest F.
Published: March 2018

The first generation of computerized medical records stored the data as text, but these records did not bring any improvement in information manipulation. The use of a relational database management system (DBMS) has largely solved this problem as it allows for data requests by using SQL. However, this requires data structuring which is not very appropriate to medicine. Moreover, the use of templates and icon user interfaces has introduced a deviation from the paper-based record (still existing). The arrival of hypertext user interfaces has proven to be of interest to fill the gap between the paper-based medical record and its electronic version. We think that further improvement can be accomplished by using a fully document-based system. We present the architecture, advantages and disadvantages of classical DBMS-based and Web/DBMS-based solutions. We also present a document-based solution and explain its advantages, which include communication, security, flexibility and genericity.
Term Domain Distribution Analysis: a Data Mining Tool for Text Databases
Authors: Chu W. W. , Parker D. S. , Goldman R. M. , Goldman J. A.
Published: March 2018

In this paper, we give a case history illustrating the real-world application of a useful technique for data mining of text databases. The technique, which we call Term Domain Distribution Analysis (TDDA), consists of keeping track of term frequencies for specific finite domains and announcing significant differences from standard frequency distributions over these domains as a hypothesis. TDDA is part of a larger framework, the Digital Filter Model, for data mining of text documents. In the case study presented, the domain of terms was the pair {right, left}, over which we expected a uniform distribution. In analyzing term frequencies in a thoracic lung cancer database, the TDDA technique led to the surprising discovery that primary thoracic lung cancer tumors appear in the right lung more often than the left lung, with a ratio of 3:2. Treating the text discovery as a hypothesis, we verified this relationship against the medical literature in which primary lung tumor sites were reported, using a standard χ2 statistic. We subsequently developed a working theoretical model of lung cancer that may explain the discovery. This discovery and our model may change how oncologists view the mechanisms of primary lung tumor location.
Level of Evidence as a Future Gold Standard for the Content Quality of Health Resources on the Internet
Authors: Amsallem E. , Haugh M. , Lukacs B. , Leroux V. , Thirion B. , Weber J. , Boissel J. P. , Darmoni S. J.
Published: March 2018

Objective: An assessment of the quality of health information on the Internet is an absolute necessity. In this study ‘sensitive’ information was defined as information found in documents published on the Internet, which could be used in a medical decision. For sensitive information, the main criterion chosen for the quality of the information was an indication of the level of evidence. A survey was conducted using the CISMeF health catalogue to assess how often a score of the level of evidence is mentioned in the information accessible on the Internet in French-language health resources.

Methods: Since 1999, members of the CISMeF team have systematically been searching for all documents containing ‘sensitive’ information and verifying whether the level of evidence was explicitly indicated as a score at least once in the document.

Results: As of June 2001, 10,190 resources were included in CISMeF; including 2964 textual ‘sensitive’ resources (29.1%). Out of all these resources, only 4.7% (95% confidence interval: 4.0 - 5.5%) indicated the level of evidence. A statistically significant difference in the prevalence of indicating the level of evidence according to resource types (e.g., 18.1% for guidelines compared to 0.0% for teaching material), year of publication (almost three times greater in 1997-2001 compared with 1990-1996) and publishers was observed.

Conclusion: As the number of people accessing the growing amount of information on the Internet is increasing daily, publishers have an ethical obligation to inform their readers about the validity of ‘sensitive’ information their sites contain. However, the vast majority of the French language Internet resources that were surveyed do not mention a score of the level of evidence for their sensitive information.
Representation of Practice Guidelines with XML – Modeling with XML Schema
Authors: Schweiger R. , Dudeck J. , Hoelzer S.
Published: March 2018

Objectives: Data and information in medicine are mainly represented in slightly structured or even unstructured, narrative text documents. It is nearly impossible to detect and handle relationships between data elements within narrative documents or to retrieve parts of documents that contain specific information. But information access and retrieval are essential to serve the delivery and application of evidence-based medicine.

Methods: The eXtensible Markup Language (XML) provides a standard means to explicitly describe a document‘s structure and to identify meaningful elements inside textual narrations. Information about the state-of-the-art medical care can be delivered to the physician by different means and media. Clinical practice guidelines are thought to be one possible solution to summarize and present current medical evidence.

Results: The structuring of resources containing medical information with XML can facilitate the provision of problem-specific medical information at the point of care by improving content retrieval and presentation. In our project, the XML Schema is used for the electronic representation in order to structure guidelines (and other text-based resources) in a standardized way.

Conclusion: The transition from unstructured textual data towards structured and coded data will be a migration process. One of the premises of our approach is that the structure that is defined by the information model doesn‘t restrict the content of the documents. This approach may fill the gap between computerized, algorithmic guideline recommendations and text-based guideline distributions.
Medical Decision Support Systems: Old Dilemmas and new Paradigms?
Authors: Dufour J.-C. , Staccini P. , Gouvernet J. , Bouhaddou O. , Fieschi M.
Published: March 2018

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.
An Architecture for a Brain-Image Database
Authors: Herskovits E. H.
Published: March 2018

The widespread availability of methods for noninvasive assessment of brain structure has enabled researchers to investigate neuroimaging correlates of normal aging, cerebrovascular disease, and other processes; we designate such studies as image-based clinical trials (IBCTs). We propose an architecture for a brain-image database, which integrates image processing and statistical operators, and thus supports the implementation and analysis of IBCTs. The implementation of this architecture is described and results from the analysis of image and clinical data from two IBCTs are presented. We expect that systems such as this will play a central role in the management and analysis of complex research data sets.
Evaluation of Three Swedish ICD-10 Primary Care Versions: Reliability and Ease of Use in Diagnostic Coding
Authors: Petersson H. , Åhlfeldt H. , Strender L.-E. , Nilsson G.
Published: March 2018

If computer-stored information is to be useful for purposes other than patient care, reliability of the data is of utmost importance. In primary healthcare settings, however, it has been found to be poor. This paper presents a study on the influence of coding tools on reliability and user acceptance. Six general practitioners coded 152 medical problems each by means of three versions of ICD-10, one with a compositional structure. At code level the reliability was poor and was almost identical when the three versions were compared. At aggregated level the reliability was good and somewhat better in the compositional structure. Ideas for improved user acceptance arose, and the study explored the need for several different tools to retrieve diagnostic codes.
WEB-Enabled Medical Databases: a Threat to Security?
Authors: Dempsey B. J. , Herrin J.
Published: March 2018

An increasing number of clinical databases are being adapted to allow access through Internet protocols, particularly Hypertext Transfer Protocol (HTTP). The World Wide Web (WWW) provides a user-friendly, standardized, broadly distributed database interface; at the same time, it may also present a threat to the security and confidentiality of patient data. However, there is little empirical evidence concerning such threats. Using publicly available records we estimate the additional risk of security violations due to web-enabling a database. The evidence, though limited, suggests that the additional risk may be small relative to more traditional security threats.
Identification of Patients at High Cardiovascular Risk: a Critical Appraisal of Applicability of Statistical Risk Prediction Models
Authors: Colombet I. , Degoulet P. , Chatellier G. , Dréau H.
Published: March 2018

Assessment of cardiovascular risk is widely proposed as a basis for taking management decisions about patients presenting with hypertension or hypercholesterolemia. Our aim was to critically assess the use of risk equations derived from epidemiological studies for the purpose of identifying high-risk patients.

Risk equations were retrieved from the MEDLINE database and then applied to a data set of 118 patients. This data set was an evaluation study of the clinical value of the World Health Organization 1993 hypertension guidelines for the decision to treat mild hypertensive patients. We calculated agreement: 1) between equations and 2) between equations and the decision to treat taken by the physician.

Most models were not applicable to our population, mainly because the original population had a narrow age range or comprised only males. Between-model agreement was better for the lower and upper risk quintiles than for the three other risk quintiles (0.58, 0.33, 0.34, 0.45, 0.70, from the lower to the upper risk quintile). When using an arbitrary threshold for defining high-risk patients (i.e. >2% per year), we observed a huge variation of the proportion of patients classified at high risk (from 0 to 17%). There was a poor agreement between risk models and the decision to treat taken by the physician. These results suggest that risk-based guidelines should be validated before their diffusion.
Evaluation of Complication Rates after Coronary Artery Bypass Surgery using Administrative Data
Authors: Hall R. E. , Ash A. S. , Rosen A. K. , Moskowitz M. A. , Ghali W. A.
Published: March 2018

Our objectives were (1) to determine if studying hospital complication rates after coronary artery bypass graft (CABG) surgery provides information not available when only mortality is studied, and (2) to reexplore the utility of ICD-9-CM administrative data for CABG outcomes assessment. Using data from Massachusetts, we identified CABG cohorts from 1990 and 1992 to respectively develop and validate multivariate risk adjustment models predicting in-hospital mortality and complications. The resulting models had good discrimination and calibration. In 1992, adjusted hospital complication rates ranged widely from 13.0% to 57.6%, while mortality rates ranged from 1.4% to 6.1 %. Hospitals with high complication rates tended to have high mortality (r = 0.74, P = 0.006), but 2 of the 12 hospitals studied ranked quite differently when judged by complications rather than mortality. We conclude that (1) complications after CABG occur frequently and may provide information about hospital quality beyond that obtained from hospital mortality rates, and that (2) administrative data continue to be a promising resource for outcomes research.
Informatics Methodologies for Evaluation Research in the Practice Setting
Authors: Buteau M. , Richards Y. , Delisle E. , Laplante P. , Niyonsenga T. , Xhignesse M. , Grant A.
Published: March 2018

A continuing challenge in health informatics and health evaluation is to enable access to the practice of health care so that the determinants of successful care and good health outcomes can be measured, evaluated and analysed. Furthermore the results of the analysis should be available to the health care practitioner or to the patient as might be appropriate, so that he or she can use this information for continual improvement of practice and optimisation of outcomes. In this paper we review two experiences, one in primary care, the FAMUS project, and the other in hospital care, the Autocontrol project. Each project demonstrates an informatics approach for evaluation research in the clinical setting and indicates ways in which useful information can be obtained which with appropriate feed-back and education can be used towards the achievement of better health. Emphasis is given to data collection methods compatible with practice and to high quality information feedback, particularly in the team context, to enable the formulation of strategies for practice improvement.
Utilizing Data Systems to Develop and Monitor Occupational Health Programs in a Large Canadian Hospital
Authors: Yassi A.
Published: March 2018

With rapid change in health care requiring greater emphasis on productivity and quality management, occupational health hazards in hospitals have been receiving increasing recognition, now not only focusing on controlling infection, but also on chemical, physical, mechanical as well as psychosocial hazards. Reducing costly time loss from musculoskeletal injuries is a particular imperative. The Department of Occupational and Environmental Medicine at Winnipeg's Health Sciences Centre, developed databases to help priorize, monitor and improve occupational health programs for its 6,000 employees. Risk assessment/risk management models were adopted to identify hazards, quantify risks and priorize intervention. Using the databases permitted the targeting of groups requiring immunization, resulting in increased coverage. New safety products were introduced and found to be cost-beneficial. A return-to-work post-injury program was particularly cost-beneficial. Over the five years following the implementation of occupational health programs, workers' compensation assessment reductions resulted in savings of more than half-a-million dollars annually. The databases were invaluable in affecting these changes.
The SNOMED Model: A Knowledge Source for the Controlled Terminology of the Computerized Patient Record
Authors: Rothwell D. J. , Côté R. A. , Lussier Y. A.
Published: March 2018

This article will present a description ofthe semi-implicit semantic properties of the Systematized Nomenclature of Human and Veterinary Medicine, also called SNOMED International. It will focus on the formalism of SNOMED and its computational properties using the disease definition as an example. Additional information will be provided in order to convert semi-implicit links found between SNOMED concepts into explicit computational semantic links.
A Psychiatric Diagnostic System Integrating Probabilistic and Categorical Reasoning
Authors: Satomura Y. , Honda M. , Sato T. , do Amaral M. B.
Published: March 2018

We describe a diagnostic support system for clinical psychiatry and its evaluation results. The system has two inter-related components: a rule-based reasoning part associated with uncertainty, and a deterministic part, that uses heuristics to perform categorical reasoning. The system includes the 30 groups of psychiatric diagnoses which are classified under the categories 290 to 319 of the DSM-III-R and the ICD-9. There are, in fact, 1508 rules relating 208 clinical findings with 257 diagnoses. The reasoning strategy is based on selecting and differentiating diagnostic categories in a hierarchical classification tree. The system is intended to be used for education of medical students, and to help non-specialist clinicians, residents in psychiatry, or experts with few years of experience in decision making. We tested the diagnostic performance of the system using case reports extracted from a specialized journal. In 52.8% of the cases, the correct diagnosis was ranked as the first hypothesis using only the rule-based part. In combination with the deterministic strategy, the correct diagnosis could be made for 73.6% of the analyzed cases.
Attitudes of Community Pharmacists, University-Based Pharmacists, and Students Toward On-Line Information Resources
Authors: Jacknowitz A. I. , Abate M. A. , Shumway J. M.
Published: March 2018

The study sought to explore the attitudes of community pharmacists, university-based pharmacists, and pharmacy students before and after exposure to computerized systems of on-line information services. A 42-item attitudinal survey was administered to 21 community pharmacists, 7 university clinical pharmacist faculty, and 17 senior pharmacy students, prior to and at the end of a year of access to Grateful Med® and BRS Colleague®. Few significant differences were noted among the participants at baseline. No significant interaction-effect differences for type of participant or system used were found. Participants were generally positive about computers in general, the accuracy of on-line information services, their impact on knowledge and confidence, and their usefulness for pharmacists.
Coding Clinical Information: Analysis of Clinicians Using Computerized Coding
Authors: Kadlec P. , Puerner F. , Hohnloser J. H.
Published: March 2018

Data are presented of a controlled experiment with a computerized browsing and encoding tool. Eighteen practicing clinicians extracted medical concepts from two narrative exercise cases using two approaches, traditional and computer-assisted use of ICD-9.

Our results indicate that by using a computerized coding tool the completeness of coding can be improved by up to 55%, that by enforcing mandatory as opposed to optional modifier codes results in lower rates of incomplete coding (0 and 55%, respectively), higher rates of correct coding (41 to 92%) and no change in incorrect code, and that manual coding takes twice as long than coding with the help of the computerized coding tool. Clinicians need 59% more time for processing the whole set of codes than is suggested by the sum of individual codes. We conclude that the use of a computerized coding tool can save time and result in higher quality codes. However, the real time spent on coding may be underestimated when looking at individual coding times, instead of the whole task of processing a clinical scenario.