Candidemia in a Portuguese tertiary care hospital: Analysis of a 2-year period.

BACKGROUND: Candidemia is a nosocomial infection of increasing importance, associated with high morbidity and mortality. The aim of this study is to describe the species distribution, risk factors, management and outcomes of patients with candidemia. METHODS: We conducted a retrospective study at Centro Hospitalar Universitário de São João, Portugal, between January 2016 and December 2017. RESULTS: A total of 117 candidemia episodes (n=114 patients) were included. Median age was 65 years, with an increased prevalence of older ages. Candida albicans (51.3%) was the most prevalent species, followed by C. glabrata (22.2%), C. parapsilosis (15.4%), C. tropicalis (4.3%) and C. lusitaniae (2.6%). Forty-two patients (35.9%) did not receive antifungal drugs after diagnosis of candidemia. Echinocandins were used as first-line drug therapy in half of the treated patients (50.7%). The median EQUAL Candida Score was 6/17 (IQR 6-9) for patients without central venous catheter (CVC) and 11/20 (IQR 6-14) for patients with CVC. The 30 days-mortality was 31,6% and was not significantly associated with the timing of antifungal therapy and the EQUAL Candida Score. CONCLUSION: The distribution of Candida species has changed in recent years, with an increase in the proportion of C. albicans and C. glabrata. Rapid diagnostic tests, empiric antifungal therapy and source control are essential to improve the prognosis of patients with candidemia. More multicentric prospective studies are needed to evaluate the association of mortality with the timing of antifungal therapy or the EQUAL Candida Score.

Improved embryonic cryosurvival observed after in vitro supplementation with conjugated linoleic acid is related to changes in the membrane lipid profile.

The aim of this study was to evaluate the effect of supplementing serum-containing media with a mixture of cis- and trans-9,11- and -10,12-conjugated isomers of linoleic acid (CLA) during different steps of the in vitro production (IVM, IVC, or IVM + IVC) of bovine embryos on their embryonic development, cryotolerance, and lipid profile. To evaluate the impact of the CLA on membrane lipids, such as phosphatidylcholine (PC) and sphingomyelin (SM), the embryos' lipid profiles were obtained using matrix-assisted laser desorption ionization mass spectrometry. The cleavage rates (78.6%-84.8%) and blastocyst development (44.8%-51.2%) remained unaltered. The postthawing reexpansion rates were higher (P < 0.05) when the CLA was added to the IVM medium (82.6%) or to the IVM + IVC medium (83.8%) than the control (69.3%) or IVC medium (63.0%). Changes in the blastocysts' lipid profile occurred when supplementation was restricted to the IVM or IVC medium. However, the most prominent effects of the CLA on the embryonic PC and SM profiles were observed when the supplement was added to IVM + IVC media, which was an increase in the level of highly unsaturated PCs containing 36 or 38 carbons, which are likely to contain CLA residues. These results showed that the molecular mechanism resulting in the improved cryosurvival, observed with CLA supplementation during bovine embryonic in vitro production, was related to the composition of structural lipids of cellular membranes and is dependent on the treatment length. Monitoring the lipid profile of embryonic membranes may improve the CLA supplementation strategy and facilitate the development of new IVC systems to improve the cryopreservation of bovine embryos and those of other domestic species.

Future Direction of IMIA Standardization. Report from the IMIA Standardization Working Group.

OBJECTIVES: Standardization in the field of health informatics has increased its importance and global alliance for establishing interoperability and compatibility internationally. Standardization has been organized by standard development organizations (SDOs) such as ISO (International Organization for Standardization), CEN (European Committee for Standardization), IHE (Integrating the Healthcare Enterprise), and HL7 (Health Level 7), etc. This paper reports the status of these SDOs' activities. METHODS: In this workshop, we reviewed the past activities and the current situation of standardization in health care informatics with the standard development organizations such as ISO, CEN, IHE, and HL7. Then we discussed the future direction of standardization in health informatics toward "future medicine" based on standardized technologies. RESULTS: We could share the status of each SDO through exchange of opinions in the workshop. Some WHO members joined our discussion to support this constructive activity. CONCLUSION: At this meeting, the workshop speakers have been appointed as new members of the IMIA working groups of Standards in Health Care Informatics (WG16). We could reach to the conclusion that we collaborate for the international standardization in health informatics toward "future medicine".

The Brazilian National Health Informatics Strategy.

This paper describes the Brazilian National Strategy for the development of the national Health Informatics Infrastructure. An overall description of the use of IT in the Brazilian Health scenario is presented with emphasis on the federal initiatives by DATASUS, the informatics division of the Ministry of Health. The national health card project is discussed and the strategies to establish interoperability among systems are presented. The adopted standards and methodologies used are also discussed.

[Uveitis]. / Uveíte.

Uveitis is a general term that refers to the inflammation of uveal tract, which is an important cause of blindness in young people. It is well known that uveitis can be the initial manifestation of a systemic disease (S.D.), and may appear years before the diagnosis of the primary disease. Uveitis should be integrated in a systemic study with proper testing. Therefore, the diagnosis is a matter for the ophthalmologist and the Specialist in internal medicine. We have made a retrospective study of 71 patients with chronic uveitis or panuveitis. We found 54.9% of primary uveitis and 45.1% of S.D. associated uveitis, most of them with Behçet's disease (16/71) and Ankylosing Spondilytis (7/71). HLA typing of the patients showed a decreased frequency of HLA A1 and HLA A3 antigens and an increased frequency of the HLA B27 antigen, when compared to a Portuguese control population. We confirmed the important role of HLA B27 as an independent susceptibility factor for anterior uveitis. The lowest HLA A3 frequency was observed in the group of S.D. associated uveitis, which could suggest that this antigen may play a role as a factor of resistance to uveitis.

The software challenge for the next decade: the global objects scenario.

This paper discusses the advantages of developing software as pattern-based components. The design and implementation of a pattern-based suite of software components specially constructed for the electronic patient record is presented. The methodology and the lessons learned in the development of these components are discussed. Finally, some comments about the globalization and the need for more integration among component developers in a worldwide basis is discussed.

Combining a neural network with case-based reasoning in a diagnostic system.

This paper presents a new approach for integrating case-based reasoning (CBR) with a neural network (NN) in diagnostic systems. When solving a new problem, the neural network is used to make hypotheses and to guide the CBR module in the search for a similar previous case that supports one of the hypotheses. The knowledge acquired by the network is interpreted and mapped into symbolic diagnosis descriptors, which are kept and used by the system to determine whether a final answer is credible, and to build explanations for the reasoning carried out. The NN-CBR model has been used in the development of a system for the diagnosis of congenital heart diseases (CHD). The system has been evaluated using two cardiological databases with a total of 214 CHD cases. Three other well-known databases have been used to evaluate the NN-CBR approach further. The hybrid system manages to solve problems that cannot be solved by the neural network with a good level of accuracy. Additionally, the hybrid system suggests some solutions for common CBR problems, such as indexing and retrieval, as well as for neural network problems, such as the interpretation of the knowledge stored in a neural network and the explanation of reasoning.

Hycones: a hybrid approach to designing decision support systems.

Hycones II is a tool that facilitates the construction of hybrid connectionist expert systems to solve problems in classification. Hycones II provides a hybrid system that integrates frames with three types of neural network: the "combinatorial" neural model (CNM), the "Fuzzy ARTMAP" model, and the "Semantic ART" (SMART) model, a combination of the CNM and Fuzzy ART-MAP. We will compare the ability of these three models to solve diagnostic problems in two medical domains.

[Idiopathic pulmonary hemosiderosis]. / Hemossiderose pulmonar idiopática.

We report a case of a 23 year-old man admitted to hospital with cough, fever and recurrent episodes of haemoptysis. Laboratory findings, which included a pulmonary biopsy, established the diagnosis of Idiophatic Pulmonary Hemosiderosis (IPH). Despite a number of morphologic, immunologic and ultrastructural studies, the etiology and pathogenesis of this disease remain indetermined. To diagnose an IPH all the other causes of pulmonary hemorrhage must be excluded. This is a rare disease, even more rare in adults. Based on these facts the authors publish this article, which includes the case report and a literature review.

Enhancing medical database semantics.

Medical Databases deal with dynamic, heterogeneous and fuzzy data. The modeling of such complex domain demands powerful semantic data modeling methodologies. This paper describes GSM-Explorer a Case Tool that allows for the creation of relational databases using semantic data modeling techniques. GSM Explorer fully incorporates the Generic Semantic Data Model-GSM enabling knowledge engineers to model the application domain with the abstraction mechanisms of generalization/specialization, association and aggregation. The tool generates a structure that implements persistent database-objects through the automatic generation of customized SQL ANSI scripts that sustain the semantics defined in the higher lever. This paper emphasizes the system architecture and the mapping of the semantic model into relational tables. The present status of the project and its further developments are discussed in the Conclusions.

Hybrid systems: a promising solution for better decision support tools.

This paper describes HYCONES II, a tool to enable construction of tightly coupled Hybrid Connectionist Expert Systems to solve classification problems. HYCONES II integrates frames with neural networks in its hybrid knowledge base. Three neural network models (CNM, the Fuzzy ARTMAP, and the Semantic ART - SMART) are available to the knowledge engineer. SMART is a new model, introduced by this research group and based on a combination of two previous models. The validation section compares the performance of these three neural models to solve diagnostic problems in two medical domains. Finally, the present status of this project and its future developments are presented.

HYCONES II: a tool to build hybrid connectionist expert systems.

This paper describes HYCONES II--a tool to enable the construction of hybrid connectionist expert systems to solve classification problems. HYCONES II offers to the knowledge engineer a hybrid knowledge base that integrates frames with three different neural network models: the combinatorial neural model--CNM, the Fuzzy ARTMAP and the Semantic ART--SMART models. The latter is a new model, introduced by this paper, based on a combination of the two previous models. The validation section compares the performance of these three neural models to solve diagnostic problems in two medical domains. This paper also presents HYCONES II knowledge representation features, built in the symbolic component of its hybrid knowledge-base, to deal and represent fuzzy medical variables. Finally, the present status and future developments of the project are presented.

HYCONES: a hybrid connectionist expert system.

This paper describes HYCONES, a tightly-coupled Hybrid Connectionist Expert System that integrates neural networks with a symbolic approach (frames). The symbolic paradigm provides rich and flexible constructs to describe the domain knowledge, while the connectionist one provides the system with learning capabilities. The paper describes the architecture of the system, focusing on the hybrid aspects of the knowledge base and on its automatic knowledge acquisition technique from a case database. The first validation of the system is presented. At the end, a comparison with related research efforts and future developments are discussed.

Incorporating knowledge to databases--a solution to complex domains.

This paper describes the design of an integrated environment to handle information on congenital heart disease patients. A three-layer model that integrates a database, a knowledge-base and a graphical user-interface is presented. The role of each layer and its connections is discussed. The advantages of using a hypertext front-end system to present and retrieve complex data are also addressed. The current status of the project and its future developments are described in the final section.

Proposed methodology for knowledge acquisition: a study on congenital heart disease diagnosis.

This paper proposes a methodology for knowledge acquisition (KA) from multiple experts, in an attempt to elicit the heuristic rules followed by the physician in diagnosing twelve frequently occurring congenital heart diseases (CHD). Twenty-two pediatric cardiologists and twenty-three general cardiologists were interviewed with this technique; 274 interviews were conducted, 169 with the 22 experts, 105 with the 23 non-experts. A graph formalism was employed to represent their reasoning model, leading to the construction of a "mean reasoning model" for each diagnosis, separately for experts and non-experts. The results indicate that experts, compared to non-experts, tend to build knowledge representation models (KRM) that are smaller and less complex. Qualitative differences in information utilization between the two groups were also observed. Entropy analysis suggests a greater objectivity and cohesion of the experts' model.

Valor da laparotomia na doenca de Hodgkin. / Value of laparotomy in Hodgkin's disease

Os autores mostram um levantamento de 50 casos de doenca de Hodgkin tratados no Instituto Nacional do Cancer comparando-se a modificacao do estadiamento clinico e pos-operatorio, assim como os achados mais frequentes e suas complicacoes