Information fusion for diagnosis coding support.

All patient-related medical information during a hospital stay in France, has to be collected and coded in the compilation of medical units discharge documents, according to a standardized approach. The process of describing a patient disease in terms of appropriate diagnostic codes is nevertheless, a non-intuitive operation for the physician. As a consequence, coding errors, inaccuracies and missing data are frequent, leading to potentially severe economical upshots. A coding support system developed to improve medical coding results, integrates three information processing methodologies, using the outputs from various Hospital Information System applications. Each methodology generates partial heterogeneous information, with considerable semantic variety. In order to properly synthesize these outputs, information fusion is required to produce enriched contextualized information, presented to the physician as an ordered list of suggested codes. This paper explores two information fusion approaches: voting system and possibilistic. Both methods are tested on a database of 1,000 discharge summaries, to show the interest of information fusion in this context. Results show that fusion methods perform better in most of the cases than partial information extraction methods.

ANTEROCOD: actuarial survival curves applied to medical coding support for chronic diseases.

For the practitioner, choosing diagnosis codes is a non-intuitive operation. Mistakes are frequent, causing severe consequences on healthcare performance evaluation and funding. French physicians have to assign a code to all their activities and are frequently prone to these errors. Given that most of the time and particularly for chronic diseases indexed information is already available, we propose a tool named AnterOcod, in order to support the medical coding task. It suggests the list of most relevant plausible codes, predicted from the patient's earlier hospital stays, according to a set of previously utilized diagnosis codes. Our method applies the estimation of code reappearance rates, based on an equivalent approach to actuarial survival curves. Around 33% of the expected correct diagnosis codes were retrieved in this manner, after evaluating 998 discharge abstracts, significantly improving the coding task.

REFEROCOD: a probabilistic method to medical coding support.

Choosing diagnosis codes is a non-intuitive operation for the practitioner. Mistakes are frequent with severe consequences on healthcare evaluation and funding. French physicians have to assign a code for everything they do and they are not spared with these kinds of errors. We propose a tool named REFEROCOD to support the medical coding task in order to minimize errors without losing time, by suggesting a list of codes in accordance with the physician activities and of the patient medical context. The proposed method uses probabilistic knowledge and indicates the probability to have a proper diagnosis code considering the realized procedure, age, sex and other information available in the discharge abstract.

Cytokeratin immunoreactivity of intestinal metaplasia at normal oesophagogastric junction indicates its aetiology.

BACKGROUND AND AIMS: Cytokeratin (CK) 7 and 20 patterns are specific for long and short segments of Barrett's oesophagus but their use has not been assessed in intestinal metaplasia arising in macroscopically normal gastro-oesophageal junction (GOJ). PATIENTS AND METHODS: This study was carried out in a large prospective series of 254 patients who underwent upper endoscopy, had normal gastro-oesophageal anatomy, and who had biopsies of the antrum, fundus, cardia, GOJ, and lower oesophagus. Intestinal metaplasia of the GOJ was typed by histochemistry with high iron diamine-alcian blue staining and by immunohistochemistry using CK7 and CK20 antibodies. Results were correlated with clinical, endoscopic, and pathological data. RESULTS: Sixty (23.6%) of our patients presenting with a normal GOJ had intestinal metaplasia. The CK7/CK20 pattern identified two groups of patients: one highly correlated with Barrett's and the other with characteristics of Helicobacter pylori gastritis. The Barrett's type CK7/CK20 pattern was related to a high frequency of gastro-oesophageal reflux symptoms (p<0.02) and normal endoscopic appearance of the stomach (p<0.03). In contrast, the gastric type CK7/CK20 pattern was linked to atrophic (p<0.02) or erythematous (p<0.05) appearance of the stomach (p<0.03), high frequency of H pylori infection (p<0.04), antral inflammation (p<0.006) with atrophy (p<0.02), and intestinal metaplasia (p<0.02). CONCLUSION: In patients presenting with intestinal metaplasia in normal appearing GOJ, the cytokeratin pattern identifies two groups of patients, one with features identical to those of long segment Barrett's oesophagus and one with features seen in H pylori gastritis. These data may be used by clinicians and should result in improved endoscopic surveillance strategies targeted specifically at patients at increased risk of Barrett's oesophagus and thus cancer.

[Concurrent concentrated radio-chemotherapy of epidermoid cancer of the esophagus. Long-term results of a phase II national multicenter trial in 122 non-operable patients (FFCD 8803)]. / Radio-chimiothérapie concomitante concentrée des cancers épidermoïdes de l'oesophage. Résultats à long terme d'un essai national multicentrique de phase II chez 122 malades non opérables (FFCD 8803).

OBJECTIVES: Concomitant radiochemotherapy improves survival from inoperable esophageal cancer compared to radiotherapy alone. Several regimens of radiotherapy (standard or concentrated split course radiotherapy) are used, however the optimum protocol remains to be determined. The aim of this study was to analyze the efficacy and tolerance of concentrated concomitant split course radiochemotherapy. Prognostic factors as well as those positively influencing complete response were also studied. METHODS: This multicentric phase II trial looked at patients with histologically proven, inoperable, squamous cell esophageal carcinoma without metastases or invasion of the tracheobronchial mucosa. Treatment included 3 cycles of chemotherapy by 5-FU continuous infusion (800 mg/m2.d D1-D5, D22-D26, D43-D47), cisplatin (70 mg/m2 D2, D23, D44) and radiotherapy 15 Gy/5d (D1-D5, D22-26, D43-D47). Efficacy was analyzed by endoscopy, biopsy and computerized axial tomography during the 12th week of treatment. RESULTS: The trial included 122 patients from 21 centers (110 M and 12F, mean age 63.1 +/- 8.6 years, range 40-78). In accordance with the TNM-UICC classification (1978), 8 patients were classified stage I (T1 N0), 13 stage II (T2 N0), 100 stage III (T3 and/or N1) and stage was unknown in 1 patient. Median follow-up was 63 months. Treatment was complete in half of the patients. 5 premature deaths (4.1%) were recorded over the treatment period, one of which was directly linked to the toxicity of the treatment. 16% of patients showed at least one severe side-effect. 117 patients received all 3 cycles of the treatment, 88 of them without delay, and all were evaluated. 58 (47.5% of the patients included) showed a complete response with a negative biopsy, 36 (29.5%) showed a partial response, 13 (10.7%) were stable and 10 (8.2%) showed progressive disease. The median duration of complete responses was 11.5 months. Symptomatically, dysphagia improved in 80% of the cases, performance status in 40%, and weight gain was observed in 30% of the patients with weight loss. At evaluation, oral feeding was impossible in 4 patients only and possible in 113 patients; however, endoscopic treatment of the dysphagia remained necessary in 28 patients. Median survival in the 122 patients included was 13.0 +/- 1.6 months and survival rates were 52.9, 29.8 and 12.1% at 1, 2 and 5 years, respectively. Three pretherapeutic prognostic factors influenced survival in a multivariate analysis: initial severe dysphagia (risk of premature death increased 3-fold in the first year), circumferential extension and the differentiated nature of the tumor (risk of death doubled regardless of the time delay). Factors influencing a complete clinical response were an early tumor stage, a poorly differenciated tumor in patients older than 65, and no circumferential extension. The risk of recurrence was 54.8% at 1 year in the 58 patients with complete remission. Complete circumferential extension and a well or moderately differentiated tumour influenced recurrence. CONCLUSION: This trial confirms the efficacy and good tolerance of concentrated split course radiochemotherapy in patients with inoperable esophageal cancer with a 5-year survival rate of 12%. This reinforces the need for a comparative trial (split course irradiation vs standard irradiation) such as the one currently being conducted in France.

Information fusion: application to data and model fusion for ultrasound image segmentation.

Nowadays, information fusion constitutes a challenging research topic. Our study proposes to achieve the fusion of several knowledge sources. This, in order to detect the esophagus inner wall from ultrasound medical images. After a brief description of information fusion concepts, we propose a system architecture including both model and data fusion. The data fusion is accomplished using fuzzy modeling, which can be seen as a monosensor/multiple sources data fusion system. The model fusion is performed using a full-adapted snake theory, which projects the fuzzy decision into the binary decision space.

[Diagnosis of mediastinal neuro-endocrine tumor using endosonography guided transesophageal puncture biopsy]. / Diagnostic de tumeur neuro-endocrine médiastinale par ponction-biopsie transoesophagienne guidée sous échoendoscopie.

Histologic diagnosis of tumors of the mediastinum is mandatory for therapeutic management. The location and the variety of tumors are responsible for diagnostic difficulties. Endosonography guided fine-needle biopsy is an efficient and safe procedure for the diagnosis of peridigestive masses. We report the case of a patient with a neuroendocrine tumor of the mediastinum revealed by a mass syndrome. The diagnosis was performed by endosonography guided needle biopsy.

[Neuro-intellectual prognosis at school age for 62 children born with a gestational age of under 32 weeks]. / Pronostic neuro-intellectuel à l'âge scolaire de 62 enfants nés à un âge gestationnel inférieur à 32 semaines.

AIM: The aim of this study was to detail the incidence of cerebral palsy in children born before 32 weeks of gestation and to evaluate the scholastic and intellectual performance in non-handicapped children. POPULATION AND METHODS: The population included 63 survivors hospitalized in 1984-85 (gestational age: 30.06 +/- 1.21 weeks; birth weight: 1386 +/- 267 g; inborn 60%; male: 38.7%; small for gestational age: 4.8%; hyaline membrane disease: 32%; European: 98.4%). Neurodevelopmental assessment was performed by pediatricians and psychologists using Wisc-R, visual screening by Monoyer scale, hearing by audiometry realized by oto-rhinolaryngologists. RESULTS: There were 62 survivors (one child dead by sudden infant death syndrome). Fifty children evaluated at a mean age of 9.3 +/- 0.7 years and written data available for another eight. Twelve children presented with cerebral palsy. Risk factors were ultrasound abnormalities of parenchymal brain and male gender. In children without cerebral palsy, we observed 12 visual and two hearing impairment. Three were in special education, 32 were in an age-appropriate level, nine with one year below. Neonatal events were not associated with the Wisc-R results except for ultrasound abnormalities of parenchymal brain. Wisc-R was strongly correlated with familial economic and education level. CONCLUSION: School performances in non-handicapped children born before 32 weeks is satisfying. Intellectual performance is mainly correlated with familial economic and education level.

Analysis of N-nitrosamines by high-performance liquid chromatography with post-column photohydrolysis and colorimetric detection.

N-Nitrosamines eluted from reversed-phase HPLC were quantitatively photohydrolysed in a UV photoreactor in aqueous solution to give the nitrite ion which could be determined colorimetrically with the Griess reagent. The chromatographic behavior of N-nitroso compounds (including 19 volatile dialkyl and 7 non-volatile N-nitrosamines) was studied on three octadecylsilane columns. The capacity factor varies linearly with the number of carbons atom of the n-dialkyl chains. N-nitrosamines bearing di-n-alkyl chains with the same number of carbon atoms could be separated with a highly polar mobile phase. The yield of photohydrolysis depends upon pH and time of exposure under UV light. The response was shown to be linear in the 0-200 ng range with a limit of detection of 8 pmoles injected for N-dialkyl nitrosamines. This limit was 20 pmoles for N-nitrosamines bearing two phenyl groups. Although N-nitrosamines could be detected at 230 nm without post-column reaction, such a reaction enhances the specificity of detection in biological matrices such as gastric juice or alcoholic beverages.

Multicentre prospective controlled study of Barrett's oesophagus and colorectal adenomas. Groupe d'Etude de l'Oesophage de Barrett.

Previous studies have suggested that patients with Barrett's oesophagus may be at increased risk of colorectal neoplasia, though the association is disputed. In a multicentre prospective study we compared the prevalence of colorectal adenomas in patients with Barrett's oesophagus and controls. Barrett's oesophagus patients (n = 104) had histological confirmation of columnar epithelium extending more than 3 cm above the gastro-oesophageal junction. The 537 controls were patients with symptoms suggesting irritable bowel syndrome. No participant had a personal history of colonic neoplasm. Each patient underwent colonoscopy. Histologically proven adenomas were found in 26 Barrett's patients (25%) and 75 controls (14%). Three colorectal cancers were discovered in each group. The prevalence of adenomas was greater in the Barrett's oesophagus group than in the control group (p < 0.01) but the relation became non-significant after adjustment for age and sex and control for other known risk factors by a logistic regression model (odds ratio 1.4 [0.7-2.7]). The relative risk of adenoma was significantly higher in patients older than 59 than in younger patients (2.2 [1.3-3.5]) and in men than in women (3.4 [2.0-5.7]). Other factors contributing significantly to the risk of adenoma were a family history of colorectal cancer (2.3 [1.1-4.8]), rectal bleeding (2.1 [1.1-3.9]), previous colonic investigation (0.3 [0.1-0.7]), and complete as opposed to partial colonoscopy (6.4 [0.8-48.3]). We conclude that Barrett's oesophagus is not an independent risk factor for colorectal neoplasia and, therefore, is not, in itself an indication for colorectal screening.

[Therapeutic management and survival of gastric adenocarcinoma in the province of Finistère between 1984 and 1989]. / Prise en charge thérapeutique et survie de l'adénocarcinome gastrique dans le département du Finistère entre 1984 et 1989.

OBJECTIVES: The aim of this study was to analyze the evolution of treatment regimens and survival rates of stomach adenocarcinoma recorded in the Finistère cancer registry from 1984 to 1989. METHODS: In a population of 838,627 inhabitants, 1,280 patients with a gastric cancer were registered; 1,164 patients (693 males and 471 females) had an adenocarcinoma. Survival rates were estimated by the actuarial method, and compared using the logrank test and the Cox model. RESULTS: Surgical resection was the main treatment for 661 patients (57%). The frequency of curative resection increased from 25% between 1984 and 1986 to 35% after 1986. Among the other patients, 39 (3%) were treated by chemotherapy and/or radiotherapy, and 53 patients (4%) by endoscopy alone; 253 patients had only symptomatic treatment. The survival rates of all patients were 43% at 1 year and 20% at 5 years. The median survival was 9.2 +/- 0.6 months. In patients with cancer managed surgically, the factors associated with a better prognosis were young age, long duration of symptoms before diagnosis, ulcerated macroscopic aspect, limited tumour extension and curative surgical resection. In other patients, 2 factors were associated a with better prognosis: the absence of metastases and an endoscopic palliative treatment. CONCLUSIONS: Surgical resection is the main treatment of gastric adenocarcinoma. Although the frequency of surgery increased, the prognosis of gastric adenocarcinoma did not improve within this 6-year period.

Neonatal nosocomial respiratory infection with coronavirus: a prospective study in a neonatal intensive care unit.

The aim of this prospective study was to evaluate the incidence of viral respiratory infection in hospitalized premature newborn infants and to assess the role of coronaviruses. All hospitalized premature infants with a gestational age less than or equal to 32 weeks were included. Tracheal or nasopharyngal specimens were studied by immunofluorescence for coronaviruses, respiratory syncytial virus, adenoviruses, influenza and parainfluenza viruses. Forty premature infants were included; 13 samples were positive in 10 newborns (coronaviruses n = 10; influenza 1 n = 2; adenovirus n = 1). None was positive at admission. All premature infants infected with coronaviruses had symptoms of bradycardia, apnea, hypoxemia, fever or abdominal distension. Chest X-ray revealed diffuse infiltrates in two cases. However, no significant difference was observed between infected and non-infected premature infants for gestational age, birth weight, duration of ventilation, age at discharge, incidence of apnea or bradycardia. Nosocomial respiratory tract infection with coronaviruses appears to be frequent. The clinical consequences should be evaluated in a larger population.

[Treatment of and survival after epidermoid cancer of the esophagus in the department of Finistère between 1984 and 1988 (716 cases)]. / Traitement et survie du cancer épidermoïde de l'oesophage dans le département du Finistère entre 1984 et 1988 (716 cas).

The incidence of esophageal cancer in the French county of Finistère is among the highest in France (26.7/10(5) for males). The authors analyzed the survival rates for squamous cell carcinomas from data of the Finistère tumor registry in order to describe different prognostic groups of patients using the multivariate Cox model. From 1984 to 1988, 716 patients with esophageal squamous cell carcinomas were registered in an overall population of 828,000 residents: 675 males and 41 females. Survival was calculated using the actuarial method. Six hundred and seventy five patients died before the point date (31 Dec 1989). Only one patient was lost to follow-up. The actuarial survival rates of all patients were 89 +/- 1% at 3 months, 68 +/- 2% at 6 months, 37 +/- 2% at one year, 12 +/- 1% at 3 years and 6 +/- 1% at 5 years; median survival was 9.1 +/- 0.4 months. Survival was significantly related to cancer size, tumor extension and surgical contraindications. In the Cox model, age, cancer size, surgical contraindications, year of diagnosis were independent prognostic predictors. There was a significant increase in survival rates after 1986: median survival was 8.1 +/- 0.4 months between 1984 and 1986 and 10.1 +/- 0.5 months between 1987 and 1988. Patients treated by curative resection had higher actuarial survival rates (median survival 22.5 +/- 4.1 months) than patients who underwent palliative resection (median survival 11.3 +/- 1.2 months). In patients with cancer managed surgically, the prognostic predictors were tumor size, curative vs palliative surgical resection and association with chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Endosonography can detect residual tumour infiltration after medical treatment of oesophageal cancer in the absence of endoscopic lesions.

Endoscopic ultrasound (endosonography) is useful in the preoperative staging of oesophageal tumours. It may also have a role in evaluation and surveillance of patients with inoperable carcinomas. Thirty four patients with inoperable oesophageal cancer were investigated by endosonography and computed tomography before medical treatment. In 10 patients receiving combined chemotherapy and radiotherapy, the endoscopic lesions resolved and biopsy specimens were negative. When endosonography suggested the persistence of tumour infiltration in these patients, a local recurrence or distant metastases appeared within a few months. In contrast, when no infiltration was detected, no tumoral recurrence or progression was observed within eight months. These results suggest that endosonography is better than endoscopic biopsy specimens and computed tomography in assessing the response of oesophageal carcinoma to non-surgical treatment.

Differences in hepatic microsomal cytochrome P-450 isoenzyme induction by pyrazole, chronic ethanol, 3-methylcholanthrene, and phenobarbital in high alcohol sensitivity (HAS) and low alcohol sensitivity (LAS) rats.

High and low alcohol sensitivity (HAS and LAS) rats have been selected for their differences in ethanol-induced sleep time. Liver monooxygenase activities were studied in HAS and LAS rats before and after treatments with known inducers such as chronic ethanol, pyrazole, 3-methylcholanthrene (3-MC) and phenobarbital (PB) to determine whether the selection procedure also selected for differences in the cytochrome P-450 (P-450) inducibility. This previously has been shown with long sleep (LS) and short sleep (SS) mice, which were selected using a similar criterion. 3-MC and PB, in conjunction with chronic ethanol treatment, were used in order to evaluate the interactions of ethanol with these inducers. Prior to treatment, total P-450 content was slightly lower in LAS than in HAS rats. However, both lines displayed the same microsomal monooxygenase activities related to different P-450 isozymes. This was demonstrated by ethoxyresorufin deethylation (EROD) for cytochrome P-450 1A1 (CYP1A1), acetanilide hydroxylation (ACET) for CYP1A2, pentoxyresorufin dealkylation (PROD) for CYP2B, 1-butanol oxidation (BUTAN) and N-nitrosodimethylamine demethylation (NDMA) for CYP2E1. After the different treatments, HAS rats did not differ from LAS rats in their CYP2E1 inducibility. However, pyrazole, PB and 3-MC treatment led to differences in CYP1A and CYP2B monooxygenase activities between the two lines. The enhancement of PROD by pyrazole treatment was less prominent in LAS (1.7-fold of the control value) than in HAS rats (3.8-fold).(ABSTRACT TRUNCATED AT 250 WORDS)

[Variations of the skin permeability in premature newborn infants. Value of the skin vasoconstriction test with neosynephrine]. / Variations de la perméabilité cutanée du nouveau-né prématuré. Intérêt d'un test de vasoconstriction cutanée par la Néosynéphrine.

BACKGROUND: The skin of preterm infants is defective as a barrier and does not function like that of mature until about 2 weeks of age. METHODS: Percutaneous drug absorption was studied by observing the blanching response to aqueous solutions of 10% Neosynephrin applied to a small area of skin on the internal surface of the thigh. The subjects, 10 preterm infants born at gestational ages 29 to 32 weeks (mean: 31 weeks 2 days), were tested when they were aged from day 0 to 7. The controls were 8 normal newborns aged 2 days. All preterm infants were tested a second time at the age 7 to 17 days (mean: 10 days). The blanching response was measured after 5 minutes, and graded on a scale of 0 to 4. RESULTS: The first test was positive grade 2 to 4 in all the preterm babies, while it was negative in the normal newborns. The second test was negative in 7 of the 10 preterm infants; in other 3, the grade was at least 50% lower. Infants nursed under radiant heaters were not different from the other infants. CONCLUSION: Skin permeability is increased in immature infants, but falls steadily until about the age of 10 days. The results of the Neosynephrin test could be useful in predicting the response to topically administered drug.