An information retrieval system for computerized patient records in the context of a daily hospital practice: the example of the Léon Bérard Cancer Center (France).

BACKGROUND: A full-text search tool was introduced into the daily practice of Léon Bérard Center (France), a health care facility devoted to treatment of cancer. This tool was integrated into the hospital information system by the IT department having been granted full autonomy to improve the system. OBJECTIVES: To describe the development and various uses of a tool for full-text search of computerized patient records. METHODS: The technology is based on Solr, an open-source search engine. It is a web-based application that processes HTTP requests and returns HTTP responses. A data processing pipeline that retrieves data from different repositories, normalizes, cleans and publishes it to Solr, was integrated in the information system of the Leon Bérard center. The IT department developed also user interfaces to allow users to access the search engine within the computerized medical record of the patient. RESULTS: From January to May 2013, 500 queries were launched per month by an average of 140 different users. Several usages of the tool were described, as follows: medical management of patients, medical research, and improving the traceability of medical care in medical records. The sensitivity of the tool for detecting the medical records of patients diagnosed with both breast cancer and diabetes was 83.0%, and its positive predictive value was 48.7% (gold standard: manual screening by a clinical research assistant). CONCLUSION: The project demonstrates that the introduction of full-text-search tools allowed practitioners to use unstructured medical information for various purposes.

Benchmarking French regions according to their prevalence of healthcare-associated infections.

OBJECTIVE: To propose an original method of benchmarking regions based on their prevalence of healthcare-associated infections (HAIs) and to identify regions with unusual results. DESIGN: To study between-region variability with a three-level hierarchical logistic regression model and a Bayesian non-parametric method. SETTING: French 2006 national HAIs point prevalence survey. PARTICIPANTS: A total of 336 858 patients from 2289 healthcare facilities in 27 regions. Patients with an imported HAI (1% of the data, 20.7% of infected patients), facilities with <5 patients and patients who had at least one missing value for the variables taken into account were excluded (5.0% of patients). MAIN OUTCOME MEASURE: Binary outcome variable indicates whether a given patient was infected. RESULTS: Two clusters of regions were identified: one cluster of five regions had a lower adjusted prevalence than the other one of 22 regions, while no region with unusually high prevalence could be identified. Nevertheless, the degree of heterogeneity of odds ratios between facilities for facility-specific effects of use of invasive devices was more important in some regions than in others. CONCLUSIONS: The adjusted regional prevalence of HAIs can serve as an adequate benchmark to identify regions with concerning results. Although no outlier regions were identified, the proposed approach could be applied to the data of the 2012 national survey to benchmark regional healthcare policies. The estimation of facility-specific effects of use of invasive devices may orient future regional action plans.

Automated detection of nosocomial infections: evaluation of different strategies in an intensive care unit 2000-2006.

The aim of this study was to evaluate seven different strategies for the automated detection of nosocomial infections (NIs) in an intensive care unit (ICU) by using different hospital information systems: microbiology database, antibiotic prescriptions, medico-administrative database, and textual hospital discharge summaries. The study involved 1,499 patients admitted to an ICU of the University Hospital of Lyon (France) between 2000 and 2006. The data were extracted from the microbiology laboratory information system, the clinical information system on the ward and the medico-administrative database. Different algorithms and strategies were developed, using these data sources individually or in combination. The performances of each strategy were assessed by comparing the results with the ward data collected as a national standardised surveillance protocol, adapted from the National Nosocomial Infections Surveillance system as the gold standard. From 1,499 patients, 282 NIs were reported. The strategy with the best sensitivity for detecting these infections using an automated method was the combination of antibiotic prescription or microbiology, with a sensitivity of 99.3% [95% confidence interval (CI): 98.2-100] and a specificity of 56.8% (95% CI: 54.0-59.6). Automated methods of NI detection represent an alternative to traditional monitoring methods. Further study involving more ICUs should be performed before national recommendations can be established.

[Use of the French medico-administrative database (PMSI) to detect nosocomial infections in the University hospital of Lyon]. / Intérêt de l'utilisation des données du Programme médicalisé des systèmes d'information (PMSI) pour la surveillance des infections nosocomiales aux Hospices Civils de Lyon.

BACKGROUND: Surveillance is an effective element in the fight against nosocomial infections, but the monitoring methods are often cumbersome and time consuming. The detection of infection in computerized databases is a means to alleviate the workload of health care teams. The objective of this study was to evaluate the performance of using discharge summaries in medico-administrative databases (PMSI) for the identification of nosocomial infections in surgery, intensive care and obstetrics. METHODS: The retrospective assessment study included patients who were hospitalized in general surgery, intensive care and obstetrics at different periods of time in 2006 and 2007 depending on the wards. Patients were monitored according to standard protocols which are coordinated at the regional level by the Southeast coordinating centre (CCLIN). The performance of identifying cases of nosocomial infection from discharge diagnoses coded by using the International Classification of Diseases (tenth revision) was evaluated by a study of sensitivity, specificity, positive and negative predictive values with their 95% confidence intervals. RESULTS: Using a limited number of diagnostic codes, the sensitivity and specificity were, respectively, 26.3% (95% CI 13.2-42.1) and 99.5% (95% 98.8-100.0) for the identification of surgical site infections. By expanding the number of diagnostic codes, the sensitivity and specificity were 78.9% (95% CI 65.8-92.1) and 65.7% (95% CI 61.0-70.3). The sensitivity and specificity for case identification of nosocomial infections in intensive care were 48.8% (95% CI 42.6-55.0) and 78.4% (95% CI 76.1-80.1), and were 42.9% (95% CI 25.0-60.7) and 87.3% (95% CI 85.2-89.3) for identification of postpartum infections. CONCLUSION: The PMSI is not a sufficiently efficient method in terms of sensitivity to be used in surveillance of nosocomial infections. A reassessment of the PMSI must be considered, with changes in coding of comorbidity that occurred in 2009.

Reducing surgical site infection incidence through a network: results from the French ISO-RAISIN surveillance system.

Surgical-site infections (SSIs) are a key target for nosocomial infection control programmes. We evaluated the impact of an eight-year national SSI surveillance system named ISO-RAISIN (infection du site opératoire - Réseau Alerte Investigation Surveillance des Infections). Consecutive patients undergoing surgery were enrolled during a three-month period each year and surveyed for 30 days following surgery. A standardised form was completed for each patient including SSI diagnosis according to standard criteria, and several risk factors such as wound class, American Society of Anesthesiologists (ASA) score, operation duration, elective/emergency surgery, and type of surgery. From 1999 to 2006, 14,845 SSIs were identified in 964,128 patients (overall crude incidence: 1.54%) operated on in 838 participating hospitals. The crude overall SSI incidence decreased from 2.04% to 1.26% (P<0.001; relative reduction: -38%) and the National Nosocomial Infections Surveillance system (NNIS)-0 adjusted SSI incidence from 1.10% to 0.74% (P<0.001; relative reduction: -33%). The most significant SSI incidence reduction was observed for hernia repair and caesarean section, and to a lesser extent, cholecystectomy, hip prosthesis arthroplasty, and mastectomy. Active surveillance striving for a benchmark throughout a network is an effective strategy to reduce SSI incidence.

Hospital-acquired influenza: a synthesis using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement.

Nosocomial influenza outbreaks occur in almost all types of hospital wards, and their consequences for patients and hospitals in terms of morbidity, mortality and costs are considerable. The source of infection is often unknown, since any patient, healthcare worker (HCW) or visitor is capable of transmitting it to susceptible persons within hospitals. Nosocomial influenza outbreak investigations should help to identify the source of infection, prevent additional cases, and increase our knowledge of disease control to face future outbreaks. However, such outbreaks are probably underdetected and underreported, making routes of transmission difficult to track and describe with precision. In addition, the absence of standardised information in the literature limits comparison between studies and better understanding of disease dynamics. In this study, reports of nosocomial influenza outbreaks are synthesised according to the ORION guidelines to highlight existing knowledge in relation to the detection of influenza cases, evidence of transmission between patients and HCWs and measures of disease incidence. Although a body of evidence has confirmed that influenza spreads within hospitals, we should improve clinical and virological confirmation and initiate active surveillance and quantitative studies to determine incidence rates in order to assess the risk to patients.

Nine-year downward trends in surgical site infection rate in southeast France (1995-2003).

The aim of this study was to estimate temporal trends in the incidence of surgical site infection (SSI) using a large SSI surveillance network in southeast France from 1995 to 2003. Data were analysed from 187 surgical wards that had participated in the network for at least two years. The change in SSI rate over time was modelled using a hierarchical logistic regression model with patients clustered within surgical wards. Of the 200 207 patients selected, 3786 (1.9%) had an SSI. The nine-year trend in SSI rate estimated by an odds ratio of 0.95 (95% confidence interval 0.93-0.97) was interpreted as a 5% decrease in SSI rate per year. This decrease was constant over the study period and was observed for almost all of the different types of surgical operations (orthopaedic, gastrointestinal, urology, etc). Overall SSI rates were reduced by 45% over a period of nine years. This trend was maintained even when taking into account the heterogeneity of the surgical wards and the diversity of patient demographics over time. From this, the 5% decrease per year can be reasonably interpreted as a result of preventive measures taken by surgical wards to reduce SSIs.

[Evaluation of seven immunochromatographic assays for the rapid detection of human rotaviruses in fecal specimens]. / Evaluation de sept réactifs d'immunochromatographie pour détecter les rotavirus humains dans les selles.

Seven commercially available immunochromatographic assays were tested for the rapid detection of group A rotaviruses in fecal samples compared to a enzyme immunoassay (Argene). Detection of rotaviruses in 80 ELISA positive frozen stool samples showed rates superior to 90% for three reagents (Rota Strip (Cypress Diagnostics), 98.8%; Rotascreen (Microgen), 95.0%; VIKIA Rota/Adeno (bioMérieux), 92.5%); from 82.5% to 88.8% for three others (Diarlex with centrifugation (Orion Diagnostica), 88.8%; Combo Rota/Adeno (All Diag), 87.5%; Rota/Adeno Combi Stick (bmd), 82.5%) and only 70.0% for Diarlex with filtration vial (Orion Diagnostica). The evaluation of the specificity, performed on one hundred fresh rotavirus negative stools, did not show any false positives with any assay. Analysis of the different technical features of these tests showed that they are quick and suitable for a clinical laboratory and do not require expensive equipment.

Do siblings of myocardial infarction patients have a specific management of hypertension?

The aim of this study was to determine whether the management of hypertension differs between siblings of myocardial infarction patients and the general population. Siblings aged 35 to 74 years, unaffected by myocardial infarction, were drawn from the Augsburg Family Heart Study, conducted in 1996-1997 in southern Germany (n = 524). The reference group consisted of participants of the third MONICA population-based survey conducted in 1994-1995 in the same area, who were aged 35 to 74 years and also unaffected by myocardial infarction (n = 3802). Prevalence, awareness, treatment and control of hypertension (defined by blood pressure > or = 140/90 mm Hg or use of antihypertensive medication) were compared between the two groups. The result was that the prevalence of hypertension was higher in the siblings (men: age-adjusted OR = 1.31, 95% CI: 0.99-1.75; women: age-adjusted OR = 1.83, 95% CI: 1.39-2.41). Male hypertensive siblings were more often aware and treated for hypertension than male hypertensives of the reference group whereas the level of awareness and treatment was comparable between female hypertensives of the two groups. In both genders, no difference in the degree of control was shown between hypertensives of the two groups. In conclusion the siblings and their physicians should pay more attention to the family history of myocardial infarction in order to improve the management of hypertension in this high risk group.

Factors associated with self-reporting of chronic health problems in the French GAZEL cohort.

The objective of this study was to examine factors associated with self-reporting of chronic health problems. The self-reports were obtained from a questionnaire sent by mail to the French GAZEL cohort, composed of workers of a French company. The disorders reported in the questionnaire were compared with diagnoses from the sick-leave database of the company. Associations between self-reporting and characteristics were studied by multiple logistic regression analyses. Three types of characteristics were analyzed: individual, methodological and disorder-related (i.e., prevalence of chronic disorders in the general population, probable disability and probable life risk scores). In 1992, the cohort consisted of 16,534 subjects aged 38 to 53 years. The reporting rate (number of self-reports in the questionnaire divided by number of records in the sick-leave database for the disorder considered) varied from 8.9% to 100%. Self-reporting was associated with individual characteristics (gender, family status, place of residence, annual number of sick days and sick leaves), disorder-related characteristics (probable disability, prevalence) and methodological characteristics (precision of the formulation, delay between the last sick-day and the patient report). By body system, the characteristics associated with self-reporting varied greatly but the annual number of sick days, probable disability and precision of formulation were the variables which remained most often in the models. These characteristics should be particularly taken into consideration in the interpretation of epidemiological results based on self-reporting.

Can inaccuracy of reported parental history of diabetes explain the maternal transmission hypothesis for diabetes?

BACKGROUND: The mode of inheritance of type 2 diabetes mellitus is still under discussion. Several studies have suggested an excess maternal transmission, however, more recent studies could not always confirm these findings. METHODS: We investigated the frequency of a maternal and paternal history of diabetes among diabetic and non-diabetic subjects and assessed the association between diabetes and a parental history of diabetes among participants of the MONICA Augsburg study. As an extension to previous studies, unknown parental status was taken into account. RESULTS: Of the 542 diabetic probands, 25.3% reported a positive maternal history of diabetes and 10.9% reported a positive paternal history of diabetes. Among the 12,209 non-diabetic participants a positive maternal history was also more common than a positive paternal history (12.5% versus 7.1%). Conversely, an unknown paternal status was more common than an unknown maternal status in both groups (diabetic subjects: 27.9% versus 16.8%, non-diabetic subjects: 16.8% versus 8.4%). Adjusted odds ratios (OR) for the association between a parental history of diabetes and diabetes status were similar for a positive maternal (OR = 2.9, 95% CI : 2.3-3.6) and paternal history (OR = 2.8, 95% CI : 2.1-3.8) and for an unknown maternal (OR = 1.3, 95% CI : 1.0-1.8) and paternal history (OR = 1.5, 95% CI : 1.2-1.9). CONCLUSION: Our findings do not support a strong excess maternal transmission of diabetes. Epidemiological biases and failure to account for 'don't know' responses may in part explain the previously observed predominance of a maternal history of diabetes.

Tyrosine phosphorylation of the CD3-epsilon subunit of the T cell antigen receptor mediates enhanced association with phosphatidylinositol 3-kinase in Jurkat T cells.

T cell receptor signaling results both in T cell proliferation and apoptosis. A key enzyme at the intersection of these downstream pathways is phosphatidylinositol 3'-kinase (PI 3-kinase). In a previous report, we showed that the p85alpha subunit of the PI 3-kinase preferentially associated with the CD3-zeta membrane-proximal immunoreceptor tyrosine-based activation motif of the zeta chain (zetaA-ITAM) (Exley, M., Varticovski, L., Peter, M., Sancho, J., and Terhorst, C. (1994) J. Biol. Chem. 269, 15140-15146). Here, we demonstrate that tyrosine phosphorylation of CD3-epsilon can recruit the PI 3-kinase enzyme in a T cell activation-dependent manner. In vivo studies with Jurkat cells stably transfected with a CD8-CD3-epsilon chimera (termed CD8-epsilon) shows that ligation of endogenous CD3-epsilon or CD8-epsilon by specific antibodies induces tyrosine phosphorylation of CD3-epsilon or CD8-epsilon, respectively. Increased tyrosine phosphorylation correlates with increased binding of p85alpha PI 3-kinase and recruitment of PI 3-kinase enzymatic activity to CD3-epsilon or CD8-epsilon proteins. Mutagenesis studies in COS-7 cells, transiently transfected with CD8-epsilon, p85alpha, and Fyn cDNAs in various combinations, show that both Tyr170 and Tyr181 within the CD3-epsilon-ITAM are required for efficient binding of p85alpha PI 3-kinase. Thus, replacement of Tyr170 by Phe (Y170F), or Tyr181 by Phe (Y181F) significantly reduces binding of p85alpha PI 3-kinase, whereas it does not affect binding of Fyn. Further in vitro experiments suggest that a direct binding of the tandem SH2 domains of p85alpha PI 3-kinase to the two phosphorylated tyrosines in a single CD3-epsilon-ITAM may occur. The data also support a model in which a single CD3 subunit can recruit distinct effector molecules by means of TCR-mediated differential ITAM phosphorylation.

[Predictive factors for institutionalization in the context of geriatric planning in the Gironde department (France)]. / Facteurs prédictifs d'entrée en institution dans le cadre du plan gérontologique du département de Gironde (France).

The objective of this study was to investigate the predictive factors over five years follow-up of institutionalization, relevant for starting interventions in the area of Gironde (South Western France). This study deals with a longitudinal study of community residents aged 65 years and older. Of the 2792 subjects initially included in the cohort in year 1988, 2493 were selected for this study, leading to the subjects whose type of housing was known at least once over the five year follow-up (1989-1993). The statistical analysis was made with a discrete Cox proportional hazard model. Of the 2493 subjects, 150 entered an institution during the five years of follow-up, leading to a cumulative incidence of 7.1%. In the multivariate analysis, the predictive factors found in this study were age, absence of phone in the house, living in home for the aged, cognitive decline evaluated with the Mini-Mental-Status-Examination (MMSE), dependency for one item of the Lawton's scale (Instrumental Activities of Daily Living or IADLs), namely the inability to do shopping, and limited social contact with the family. These different indicators are a basis for decision making to target home care services fitted to the needs of the area.

Trends in coronary heart disease morbidity and mortality and acute coronary care and case fatality from 1985-1989 in southern Germany and south-western France.

BACKGROUND: Although it has been shown that coronary heart disease mortality rates are decreasing in industrialized countries, little is known about time trends in coronary heart disease incidence. Further, although a number of randomized clinical trials have shown that percutaneous transluminal coronary angioplasty and thrombolysis improve survival of acute myocardial infarction patients, it is not known if widespread use of these therapeutic procedures has contributed to a decrease in in-hospital case fatality on a population basis. METHODS: The change over time of coronary heart disease attack, incidence and mortality rates was assessed in men and women (35 to 64 years) using data collected between 1985 and 1989 by the Augsburg (Germany) and Toulouse (France) MONICA Centres. Acute coronary care and 28-day case fatality for hospitalized 24-h survivors were also assessed. RESULTS: Men and women from Augsburg had higher age-standarized attack, incidence and mortality rates than their Toulouse counterparts. In both centres, attack, incidence and mortality rates declined in men, but increased in women. Patients in Toulouse received more percutaneous transluminal coronary angioplasty and thrombolysis and had lower 28-day case fatality than patients in Augsburg. The therapeutic procedures, percutaneous transluminal coronary angioplasty and thrombolysis increased in both centres; however, only in Toulouse was this increase associated with a decrease (non significant) in 28-day hospital case fatality. CONCLUSION: The increase in morbidity and mortality rates of coronary heart disease in women stresses the need for preventive measures in this group. The absence of a favourable effect of acute coronary care on 28-day fatality for hospitalized 24-h survivors in the Augsburg centre will be further investigated.

Amino acid substitutions in the yeast Pichia stipitis xylitol dehydrogenase coenzyme-binding domain affect the coenzyme specificity.

Directed mutagenesis has been used to identify a set of amino acids in the Pichia stipitis xylitol dehydrogenase, encoded by the xylitol dehydrogenase gene XYL2, which is involved in specific NAD binding. Within the binding domain, a characteristic beta alpha beta-fold is centered around a glycine motif GXGXXG also containing conserved aspartate and lysine/arginine residues. The mutation D207-->G and the double mutation D207-->G and D210-->G increased the apparent Km for NAD ninefold and decreased the xylitol dehydrogenase activity to 47% and 35%, respectively, as compared to the unaltered enzyme. The introduction of the potential NADP-recognition sequence (GSRPVC) of the alcohol dehydrogenase from Thermoanaerobium brockii into the xylitol dehydrogenase allowed the mutant enzyme to use both NAD and NADP as cofactor with equal apparent Km values. Although this mutant enzyme displayed an unaltered NADP acceptance, the reduction of the NAD specificity in the stably expressed enzyme variant is an important first step towards the long-term goal to reverse the coenzyme specificity from NAD to NADP. The mutagenized XYL2 gene could still mediate growth of Saccharomyces cerevisiae transformants on xylose minimal-medium plates when expressed together with the xylose reductase gene (XYL1).

Isolation and characterization of the Pichia stipitis transketolase gene and expression in a xylose-utilising Saccharomyces cerevisiae transformant.

The gene TKT from P. stipitis, encoding the enzyme transketolase (EC 2.2.1.1), was cloned from a genomic library by hybridization with a S. cerevisiae TKT1-gene-specific probe. The nucleotide sequence determined contains an open-reading frame of 2085 base pairs (bp) encoding a protein of 695 amino acids with a predicted molecular mass of 75113 Da. The TKT gene was actively expressed in S. cerevisiae when placed under the control of the homologous PDC1(-15) promoter and could complement a S. cerevisiae tkt deletion. The TKT protein was immunologically detectable using S. cerevisiae transketolase-specific antiserum. Overexpression of the P. stipitis TKT gene in a xylose-utilizing S. cerevisiae XYL1/XYL2 integrant led to a drastically extended generation time during growth on xylose minimal medium under aerobic conditions.