Development of a comprehensive database for research on foetal acidosis.

OBJECTIVE: To develop a research database for mother-and-child clinical and laboratory data and digital foetal heart rate (FHR) recordings. METHODS: The Base Bien Naître (BBN) database was derived from a single-centre health data warehouse. It contains exhaustive data on all parturients with a singleton pregnancy, a vaginal or caesarean delivery in labour with a cephalic presentation after at least 37 weeks of amenorrhea, and a live birth between February 1st, 2011, and December 31st, 2018. On arrival in the delivery room, the FHR was recorded digitally for at least 30 min. A cord blood sample was always taken in order to obtain arterial pH (pHa). More than 6,000 recordings were analyzed visually for the risk of foetal acidosis and classified into five groups (according to the French College of Gynaecologists and Obstetricians (CNGOF) classification) or three groups (according to the International Federation of Gynaecology and Obstetrics (FIGO) classification). RESULTS: Of the 16,089 files in the health data warehouse, 11,026 were complete and met the BBN's inclusion criteria. The FHR digital recordings were of good quality, with low signal loss (median [interquartile range]: 7.0% [4.3;10.9]) and a median recording time of 304 min [190;438]). In 3.7% of the children, the pHa was below 7.10. We selected a subset of 6115 records with good-quality FHR recordings over 120 min and reliable cord blood gas data: 692 (11.3%) had at least a significant risk of acidosis (according to the CNGOF classification), and 1638 (26.8%) were at least suspicious (according to the FIGO classification). CONCLUSION: The BBN database has been designed as a searchable tool with data reuse. It currently contains over 11,000 records with comprehensive data.

Use of automated fetal heart rate analysis to identify risk factors for umbilical cord acidosis at birth.

OBJECTIVE: To identify clinical parameters and intrapartum fetal heart rate parameters associated with a risk of umbilical cord acidosis at birth, using an automated analysis method based on empirical mode decomposition. METHODS: Our single-center study included 381 cases (arterial cord blood pH at birth pHa ≤7.15) and 1860 controls (pHa ≥7.25) extracted from a database comprising 8,383 full datasets for over-18 mothers after vaginal or caesarean non-twin, non-breech deliveries at term (>37 weeks of amenorrhea). The analysis of a 120-min period of the FHR recording (before maternal pushing or the decision to perform a caesarean section during labor) led to the extraction of morphological, frequency-related, and long- and short-term heart rate variability variables. After univariate analyses, sparse partial least square selection and logistic regression were applied. RESULTS: Several clinical factors were predictive of fetal acidosis in a multivariate analysis: nulliparity (odds ratio (OR) 95% confidence interval (CI)]: 1.769 [1.362-2.300]), a male fetus (1.408 [1.097-1.811]), and the term of the pregnancy (1.333 [1.189-1.497]). The risk of acidosis increased with the time interval between the end of the FHR recording and the delivery (OR [95%CI] for a 1-min increment: 1.022 [1.012-1.031]). The risk factors related to the FHR signal were mainly the difference between the mean baseline and the mean FHR (OR [95%CI]: 1.292 [1.174-1.424]), the baseline range (1.027 [1.014-1.040]), fetal bradycardia (1.038 [1.003-1.075]) and the late deceleration area (1.002 [1.000-1.005]). The area under the curve for the multivariate model was 0.79 [0.76; 0.81]. CONCLUSION: In addition to clinical predictors, the automated FHR analysis highlighted other significant predictors, such as the baseline range, the instability of the FHR signal and the late deceleration area. This study further extends the routine application of automated FHR analysis during labor and, ultimately, contributes to the development of predictive scores for fetal acidosis.

From adverse drug event detection to prevention. A novel clinical decision support framework for medication safety.

BACKGROUND: Errors related to medication seriously affect patient safety and the quality of healthcare. It has been widely argued that various types of such errors may be prevented by introducing Clinical Decision Support Systems (CDSSs) at the point of care. OBJECTIVES: Although significant research has been conducted in the field, still medication safety is a crucial issue, while few research outcomes are mature enough to be considered for use in actual clinical settings. In this paper, we present a clinical decision support framework targeting medication safety with major focus on adverse drug event (ADE) prevention. METHODS: The novelty of the framework lies in its design that approaches the problem holistically, i.e., starting from knowledge discovery to provide reliable numbers about ADEs per hospital or medical unit to describe their consequences and probable causes, and next employing the acquired knowledge for decision support services development and deployment. Major design features of the framework's services are: a) their adaptation to the context of care (i.e. patient characteristics, place of care, and significance of ADEs), and b) their straightforward integration in the healthcare information technologies (IT) infrastructure thanks to the adoption of a service-oriented architecture (SOA) and relevant standards. RESULTS: Our results illustrate the successful interoperability of the framework with two commercially available IT products, i.e., a Computerized Physician Order Entry (CPOE) and an Electronic Health Record (EHR) system, respectively, along with a Web prototype that is independent of existing healthcare IT products. The conducted clinical validation with domain experts and test cases illustrates that the impact of the framework is expected to be major, with respect to patient safety, and towards introducing the CDSS functionality in practical use. CONCLUSIONS: This study illustrates an important potential for the applicability of the presented framework in delivering contextualized decision support services at the point of care and for making a substantial contribution towards ADE prevention. Nonetheless, further research is required in order to quantitatively and thoroughly assess its impact in medication safety.

Know thyself.

This article is part of a For-Discussion-Section of Methods of Information in Medicine on "Biomedical Informatics: We Are What We Publish" written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by this editorial and followed by a commentary paper with invited comments. In their paper, P. Elkin et al. attempt to define the fields of Medical Informatics and Bioinformatics through a bottom-up approach by searching the medical literature. This innovative approach provides interesting results that are discussed in the commentary paper. In subsequent issues the discussion may continue through letters to the editor.

Lossless watermarking of categorical attributes for verifying medical data base integrity.

In this article, we propose a new lossless or reversible watermarking approach that allows the embedding of a message within categorical data of relational database. The reversibility property of our scheme is achieved by adapting the well known histogram shifting modulation. Based on this algorithm we derive a system for verifying the integrity of the database content, it means detecting addition, removal or modification of any t-uples or attributes. Such a content integrity check is independent of the manner the database is stored or structured. We illustrate the overall capability of our method and its constraints of deployment considering one medical database of inpatient hospital stay records. Especially, we reversibly watermark ICD-10 diagnostic codes.

[Sleep in adolescents and its disorders. A survey in schools]. / Le sommeil des adolescents et ses troubles.

OBJECTIVES: Numerous studies emphasized the high prevalence of sleep problems in adolescents. However, it remains to be seen whether these problems are developmental or if they are related to pathological conditions. In order to try to answer this question, we conducted an epidemiological study investigating the prevalence and correlates of sleep disorders in a population of high school adolescents. METHOD: The sample for this investigation consisted of 652 high school students (344 males and 308 females), aged 13 to 19 years (mean age: 15.1 1.2 years), attending colleges in the North of France. Data for the study were obtained by means of revised versions of the INSERM self-report questionnaires for adolescents. One questionnaire included 113 response choice items investigating the sleep parameters and the sociodemographic, behavioural, health, and environmental condition of the subject. This questionnaire was completed by a self-portrait questionnaire including 27 response choice items about mood, anxiety, instability and the quality of relations with others. In addition, a clinical examination was performed by the clinicians of the school health department in order to investigate the medical history of the subject and his (her) pubertal development. RESULTS: In a first step, statistical analysis showed some significant differences in sleep rates and troubles between males and females. If the total sleep time was found similar in males and females, females were found exhibiting significantly earlier bedtime (p<0.01) and waking time (p<0.005) than males. In addition, trouble falling asleep (p<0.0001), nightmares (p<0.001), need for daytime sleep (p<0.05), and stimulant pill intake (p<0.05) were found significantly more frequent in females. Then, the adolescents were classified into two subgroups. "Insomnia group" included the students who answered "often" or "always" to one of the five questions about: having trouble falling asleep, the occurrence of early awakenings, their need for daytime sleep, sleeping pill intake, and bad sleep quality. "Non insomnia group" included those who answered "never" or "sometimes" in response to the five questions. Results showed that 233 adolescents (35.7%) exhibited persistent sleep disorders, insomnia type. 40.2% of females and 31.6% of males were included in the "insomnia group" (p<0.05). Pubertal development was found significantly more advanced in the "insomnia group" adolescents, more particularly in females. In the same way, concerns about body weight (46.7% vs 38.8%; p<0.005), size and shape (15% vs 8%; p<0.01) were found significantly more frequent in the "insomnia group"; 32.3% of the "insomnia group" adolescents vs 17.9% in the "non insomnia group" reported health problems (p<0.0001). School difficulties were found significantly more frequent in the "insomnia group" compared to the "non insomnia group". The proportion of subjects who have previously repeated at least one school year (p<0.01), who reported bad school performances (p<0.01), and who reported to be "sometimes" or "often" away from school (p<0.01) was significantly higher in the "insomnia group" than in the "non insomnia group". In the same way, data showed that school investing was also significantly weaker in the "insomnia group" adolescents (p<0.01). The proportion of subjects who believed that their relations with parents (12.4% vs 6%; p<0.05), teachers (21.4% vs 10.5%; p<0.0001), or peers (10.2% vs 4.1%; p<0.002) was found significantly higher in the "insomnia group". Risk behaviours were also significantly more frequent in the "insomnia group" adolescents: suicidal ideation (25.1% vs 11.7%; p<0.001), suicide attempt (7.3% vs 3.6%; p<0.05), psychotropic drug use (11% vs 4.9%; p<0.02), regular stimulant drug use (10% vs 5.1%; p<0.005), regular tobacco use (7.8% vs 2.2%; p<0.001), regular alcohol use (13.3% vs 8.3%; p<0.05), and illicit drug use (5.2% vs 1%; p<0.001). Lastly, all the dimensions of the self-portrait were found significantly more affected or negative in the "insomnia group" than in the "non insomnia group". For example, the proportion of subjects who described themself usually sad (10.2% vs 3.4%; p<0.001), anxious (54.9% vs 40.5%; p<0.0001), downcast (41.1% vs 32.6%; p<0.05), or instable (56.9% vs 41.7%; p<0.0001) was significantly higher in the "insomnia group". CONCLUSION: In this descriptive study, if some data suggest that pubertal development may be involved in the sleep rates or troubles observed in adolescents, the results also show that persistent sleep disorders are significantly associated with physical, psychological or social difficulties. In summary, this study shows that it is essential to take an interest in the quality of sleep in adolescents, which may be a way to approach their psychosocial difficulties.

[Histological diagnosis after Pap smears detecting cancer or high-grade lesion of the cervix]. / Correspondance histologique des frottis cervico--utérins détectant un cancer ou une lésion de haut grade.

OBJECTIVE: The aim of the study is to analyze the histological-cytological correlations for Pap smears having detected cancer or high-grade squamous intra-epithelial lesion (HSIL) of the cervix. PATIENTS AND METHOD: The study about 311 women is retrospective. The average age is 36.4 years. Group 1 (histological diagnosis of high-grade or invasive lesion) includes 244 women (77.5%). Group 2 (histological diagnosis other than high-grade or invasive lesion) includes 37 women (11.9%) with a presumed diagnosis of HSIL. Group 3 (absence of histological follow-up) includes 30 women (9.6%) with a presumed diagnosis of HSIL. RESULTS: In group 1, the presumed cytological diagnosis is HSIL in 229 cases, squamous carcinoma in 11 cases and adenocarcinoma in two cases. In this group, the average delay between the Pap smear and the first histology is equal to two months. It is longer than 6 months in seven cases. The diagnosis of cancer or high-grade lesion is confirmed histologically on a first biopsy of the cervix in 196 cases, a second or a third biopsy in 10 cases, an endocervical curettage in six cases and a surgical specimen in 32 cases. In the group 2, the histological diagnosis is normal-benign in 14 cases (presumed cytological false positives) and condyloma-CIN 1 in 23 cases (presumed overevaluations). DISCUSSION AND CONCLUSION: Results highlight benefits of interactive exchanges between clinicians and pathologists, and the necessity of review of discordant cases by several pathologists in due time, with written comments and coding of the conclusions of the review. Histological follow-up is late or not done in some women.

Communication of information in the homecare context.

Organizing the Homecare with new information technologies is nowadays an important challenge. Indeed, some medical evolutions as the improvement of the duration of life, the number of chronic diseases and some social evolutions, such as the quality of patient life, or economic evolutions, such as the reduction of hospitalisation costs, could benefit from homecare. In this paper, we present the problem of the communication of information in the homecare context. Some main phases have been described that compose the two homecare processes: a logistic process and a care process. The communication of information during homecare depends on the concerned phases: first, some exchanges of information from existing Information System to the Homecare Information System; then, some exchanges between the homecare system and the mobile health care actors; and then, some mails during the outcome phase. Coordination architecture is briefly described, and two different implementations for the communication of information during homecare are presented: one is using XML messages to exchange information between Information Systems; the other is using mobile tools for communicating with mobile actors.

A preprocessing method for improving data mining techniques. Application to a large medical diabetes database.

The Knowledge Discovery in Databases (KDD) methodology seems to be attractive on the analyze of large clinical databases. In the KDD process, the preprocessing step (data cleaning and handling of missing values) is paramount since it conditions the quality of the results obtained by data mining procedures and represents about 80% of the whole project time. The aims of the present study were to analyze this step and provide tools to handle inconsistent data and missing values. We have broken down the process into 3 main stages: data cleaning--explanatory study of missing values--choice of the procedure used for handling missing values. The data cleaning stage was based on a system of logical rules to correct mistakes and on cluster analysis to discard the poorly filled files. The missing-data mechanism was analyzed by means of multivariate statistical procedures. Two methods to deal with missing values were compared: imputation by the most common value (mode) and imputation using decision trees. This study was performed on a large medical diabetes database (23,601 patients) including numerous missing values. A system of logical rules allowed to correct mistakes on essential parameters (for example, the type of diabetes). Cluster analysis allowed to identify 10% of poorly filled files. After multivariate analysis, the missing-data mechanism could be considered as random. For variables with low number of missing values (< 10%) and categories (< 4), imputation using decision trees provided better results than imputation by mode.

SIGAPS: a prototype of bibliographic tool for medical research evaluation.

Evaluation of research activity is extremely important but remains a complex domain. There's no standardized methods and evaluation is often based on the scientific publications. It is easy to identify, for a researcher, all the publications realized over a given period of time. At the level of an important establishment like an University Hospital, with about 500 researchers, this sort of inventory is very difficult to realize: we have to list the researchers, to list their publications, to determine the quality of articles produced, to store retrieved data and to calculate summary statistics. We have developed a full-Web prototype, using free software which, for a given researchers' list, interrogates the Pubmed server, downloads the found references and stores them in a local database. They are then enriched with local data which allow the realization of more or less complex analyses, the automatic production of reports, or keyword search. This tool is very easy to use, allowing for immediate analysis of publications of a researcher or a research team. This tool will allow to identify those active teams to be maintained or emergent teams to be supported. It will also allow to compare candidate profiles for appointments to research posts.

Personalising e-learning modules: targeting Rasmussen levels using XML.

The development of Internet technologies has made it possible to increase the number and the diversity of on-line resources for teachers and students. Initiatives like the French-speaking Virtual Medical University Project (UMVF) try to organise the access to these resources. But both teachers and students are working on a partly redundant subset of knowledge. From the analysis of some French courses we propose a model for knowledge organisation derived from Rasmussen's stepladder. In the context of decision-making Rasmussen has identified skill-based, rule-based and knowledge-based levels for the mental process. In the medical context of problem-solving, we apply these three levels to the definition of three students levels: beginners, intermediate-level learners, experts. Based on our model, we build a representation of the hierarchical structure of data using XML language. We use XSLT Transformation Language in order to filter relevant data according to student level and to propose an appropriate display on students' terminal. The model and the XML implementation we define help to design tools for building personalised e-learning modules.

A resource server for medical training.

OBJECTIVES: We have developed a RESOURCE SERVER to collect and store various elements used by a professor during his lecture. METHODS: The server manages four types of objects: ELEMENTS, RESOURCES (set of elements referring to a given topic), INDEXES (to organize the resources for further search and use), and USERS (to identify providers, users, and access rights). If an ELEMENT s modified, the RESOURCE is automatically updated. RESULTS: An example (preparation of an anatomy lecture) explains how the RESOURCE SERVER works in three steps: organization of the training material, indexing, and retrieval. CONCLUSIONS: The RESOURCE SERVER will help instructors develop, update and share pedagogic resources for supporting their training courses, lessons and conferences. Moreover, these techniques, based on Internet technologies for easy handling of and access to these resources, allow local and distant access. Within the general framework of the French-speaking Virtual Medical University, the RESOURCE SERVER will represent an important link between data collection and its use in intelligent pedagogic training.

Security in the French-speaking Virtual Medical University.

The Medical Virtual French-Speaking University (UMVF) is a government sponsored program. The participating medical schools will share Web accessible scientific contents and develop their own teaching strategies and learner-trainer interactions. An e-learning platform will manage the access to the UMVF and its various resources. This access will require a unique identification/authentication. Users will then be guided toward those resources adapted to their profile. We recommend the use of a smart card for the identification/authentication. The connection should be secured via a SSL protocol when using critical resources such as assessment of a student, discussion between a student and a teacher and creation or modification of resources by a teacher. In other cases, secure connection will not be required. Usage rights of resources will be explicated. Critical data will be ciphered.

Information and logistics for homecare.

TELECOS is a regional project whose ambition is to use new cooperation tools, in the context of homecare, in order to facilitate the coordinated cooperative work of health actors. Homecare can improve the quality of life for the patient and reduce costs but it also induces a lot of difficulties during organisation and care. We aim at knowing more about the activity of cooperation in the homecare context and proposing a cooperation platform which answers to the specific needs generated during homecare and which integrates new applications. In this paper, we present the results of our study of homecare. The activity analysis leads us to determine two specific processes: one concerns the implementation of human and material resources and design of the homecare protocol (the logistics process) and the other concerns the coordination of the healthcare actors during effective homecare (the care process). The first process is composed of five main phases during which an healthcare professional is required as coordinator. We then present the Worklow model used to represent the cooperation activity in homecare. We describe the activity: the tasks and subtasks are represented in a declarative way. We then briefly present our prototype, devoted to homecare management, implementing the different phases of the information process, developed in JAVA.

Impact of a modelization of the task allocation problem on the design of a prescription management software for intensive care units.

After having studied the coordination in Intensive care Units we have proposed a dynamic model for improving coordination in respect of human control over the work. We have performed simulations for analysing the impact of different strategies on coordination and we have found that our task centred coordination model could be efficient to improve the health care actors coordination and the efficiency of care delivery. We have built a first prototype based on this model. This implementation uses Internet technologies.

From data collection to knowledge data discovery: a medical application of data mining.

Prison inmates are exposed to a variety of major risk factors (psychiatric disorders, suicide attempts, illicit drug use). From 1986 to 1996, the USA prison population more than doubled while in France, it increased from 35655 in 1980 to 51623 in 1995. In spite of these findings, very little information concerning the inmates population is available. At the present time, there is a desire to adopt a policy based on the prevention of recidivism, on adequate release planning and referrals to community-based services. The aim of the RAPPEL project was to build an information system for assessing the social and health status of prison inmates. The pilot project was set up at the prison of Loos and allowed the collection and analysis of nearly 15000 records. The aim of this paper is to present the extension of the project consisting in developing a regional network grouping 11 jails. Information locally available will serve as the basis for the information system of regional jails. Data mining techniques will provide solutions for the extraction of new information. Three data mining tools were experimented : association rules, classification trees and clustering. Further extension consists in a distributed approach allowing direct access to the information system by WEB tools.

Higher carbohydrate intake is associated with decreased incidence of newborn macrosomia in women with gestational diabetes.

OBJECTIVE: To study the influence of energy and macronutrient intake on infant birthweight in women with gestational diabetes mellitus undergoing intensive management. DESIGN: This prospective study evaluated the impact of intensive management of gestational diabetes on maternal and fetal morbidity, and addressed the relationship between food intake and infant birthweight. SETTING: Fifteen maternity hospitals in northern France. SUBJECTS: Ninety-nine women with gestational diabetes or gestational mild hyperglycemia diagnosed between 24 and 34 weeks of gestation were surveyed. After 1 was excluded because of a premature birth and 18 were excluded as underreporters, 80 women were included in the final analysis. Diet intake was assessed by a dietary history at the first interview, and by two 3-day diet records at the 3rd and 7th week after diagnosis. RESULTS: In a forward-stepwise regression analysis (controlling for maternal age; smoking; parity; prepregnancy BMI; pregnancy weight gain; gestational duration; infant sex; fasting and 2-hour postprandial serum glucose; insulin therapy; and energy, fat, protein and carbohydrate intake during treatment) infant birthweight was positively associated with gestational duration (beta = +0.34, P<.002), and negatively with smoking (beta = -0.27, P<.02) and carbohydrate intake (beta = -0.24, P<.03). There were no large-for-gestational-age infants among women whose carbohydrate intake exceeded 210 g/day. CONCLUSION: For women with gestational diabetes undergoing intensive management, higher carbohydrate intake is associated with decreased incidence of macrosomia. APPLICATION: These findings suggest that nutrition counseling in gestational diabetes must be directed to maintain a sufficient carbohydrate intake (at least 250 g per day), which implies a low-fat diet to limit energy intake. A careful distribution of carbohydrate throughout the day and the use of low-glycemic index foods may help limit postprandial hyperglycemia.

Social and health status of arrivals in a French prison: a consecutive case study from 1989 to 1995.

BACKGROUND: To assess the demographic, socioeconomic and health status of male arrivals in French jails and to analyze the time trends of these characteristics. METHODS: The study was carried out in a prison for detained persons and short term prisoners. Using a standardized questionnaire, we recorded the characteristics of all male detainees and prisoners arriving in the prison between 1989 and 1995. The information collected concerned: demographic data, level of education and professional status, reasons for detention or imprisonment, social and family background, lifestyle, medical and psychiatric history, suicide attempts and illicit use of drugs. The characteristics of the study population were compared with those found in the general regional population. We analyzed developing trends in the health status of the prison population as well as their socio-economic profile over a period of seven years (1989 to 1995). RESULTS: A total of 14,785 questionnaires were analyzed. Of the study population, 56% had no professional qualification, and 62% was unemployed. About two-thirds of the inmates presented psychiatric problems or problems with illicit drug use (one or several drugs). Amongst these, 70% had not had any form of care -neither therapeutic nor educational- before their arrival in prison. Between 1989 and 1995, the proportion of drug users increased by 30%. A parallel increase was observed in the level of unemployment and in the frequency of mental problems. CONCLUSIONS: Our results suggest a need for therapeutic and educational care to be provided for prison inmates. This poses a problem which needs to be addressed in terms of public health. The study also illustrates the usefulness of a standardised questionnaire for each arrival. The systematic use of such a tool would make it possible to identify inmates'needs and to propose adapted care solutions.

A modelization of the task allocation problem for prescribing activity in an ICU.

The improvement of coordination between Health Care Professionals belonging different specialities and who are extremely mobile, is a crucial problem in Medicine. A workflow System is one example of the new informatics tools which facilitate the transfer of information and responsibility between health care providers. Medical informatics systems in particular should be reactive enough to cope with the flexibility of real work situations: in this paper, we present the task allocation problem. We distinguish between the workflow control process and the notifying process, which concerns the sharing out of the tasks between the actors concerned. We focus on the impact of strategies of notification on the progress of coordinated work. We propose a simulator to model and study the different ways of sharing tasks between actors in an Intensive Care Unit's activity of prescription.