Development and utilization of paperless medical records: a unique approach.

The purpose of this article is to describe the development and utilization of a unique paperless medical record system in a large multispeciality group practice setting. The Scott and White integrated health care delivery system provides care over a 34-county area in Central Texas. Since 1988, clinicians at Scott and White have developed a text-based, content-searchable electronic medical record system known as EMRx. This system provides a single clinical data repository that allows patient care activities and aggregate data analyses to occur by using the same set of data on a daily basis. Use of this approach has led to the aggregation of over 9.8 million clinical documents since 1994. Over 1,845 health care providers used the system during May 2000 for direct patient care; 866,114 patient records have been accessed since January 1, 1999 to answer questions related to patient care, quality assurance, outcomes research, and accreditation.

An integrated data warehouse system: development, implementation, and early outcomes.

This paper describes a generic vision of global information flow and the development of an integrated data warehouse system, using clinical data on all patient encounters and administrative data on all operating transactions as part of an integrated health care system. This new integrated data warehouse system has been successfully used for multiple purposes, including patient care, health services research, resource utilization and feasibility studies. During 1999, core analyses included the electronic abstraction, aggregation, and analysis of data on over 400,000 patients. This approach to building a centralized data system comprised of multiple repositories efficiently meets a variety of individual and aggregate information needs, while reducing the need to create duplicate databases.

Fine needle aspiration biopsy of solitary fibrous tumors. Report of two cases with histologic, immunohistochemical and ultrastructural correlation.

BACKGROUND: Although the fine needle aspiration biopsy (FNAB) technique is widely applied to thoracic and soft tissue tumors, the cytologic morphology of solitary fibrous tumors is not fully established. CASES: We report the cytologic features observed on computed tomography (CT)-guided FNAB obtained from two benign solitary fibrous tumors of the pleura in two males. The cytologic findings were compared to the light and electron microscopic features. The smears were composed of spindle cells dispersed amid a delicate network of small blood vessels. scattered among these spindle cells were also epithelioid cells arranged singly or in small clusters. These cells were polygonal, with moderately dense, homogeneous or finely vacuolated, basophilic cytoplasm and a moderately high nuclear/cytoplasmic ratio. The nuclei were oval to round and slightly hyperchromatic and rarely had small nucleoli. Abundant spindle-shaped, round, naked nuclei were seen in the background. Stains for CD34 were positive in the epithelioid and spindle cells. Histologically the lesions were composed of spindle cells embedded in a collagenous matrix. Hypercellular nodules and focal hemangiopericytic and storiform patterns were also observed. There were no features suggesting malignancy. In electron microscopic evaluation there were fibroblastic cells in a collagenous matrix as well as polygonal cells singly and in clusters with scanty to moderate amounts of cytoplasm containing sparse organelles. The cells were attached to each other by tight junctions. Occasionally, cells were surrounded by short segments of basal lamina. CONCLUSION: The cytomorphologic pattern described above correlates well with the histologic and ultrastructural findings in benign solitary fibrous tumors (SFT) and corresponds perfectly to the histogenetic concept of this lesion. As with other tumors, fine needle aspiration biopsy is helpful in the evaluation of SFT.

Aspiration cytology of 131I-induced thyroiditis. A case report.

BACKGROUND: Fine needle aspiration (FNA) has become an indispensable diagnostic tool for the investigation of thyroid nodules. Although 131I may induce morphologic changes similar to those associated with external radiation, a known diagnostic pitfall, the cytology literature on the subject is very sparse. This case exemplifies the thyroid cytologic changes associated with 131I exposure. CASE: A 50-year-old male with a remote history of 131I exposure had an indurated thyroid on routine physical examination. FNA was interpreted as positive for malignant cells, and subsequently a total thyroidectomy was performed. Review of the cytologic sample revealed follicular cells with focal, marked cytologic atypia, abundant colloid, stromal fragments, and lymphocytes. The thyroidectomy specimen consisted of an indurated and nodular gland showing architecture distortion by micronodule formation, lymphocytic infiltrates, interstitial fibrosis and follicular atrophy. Marked nuclear atypia was seen in the follicular cells. CONCLUSION: FNA of thyroid glands exposed to 131I may show significantly large, atypical follicular cells in addition to classical changes of nodular goiter and/or chronic lymphocytic thyroiditis. Although the clinical history and the diffuse nature of the process may favor a benign process in most cases, the presence of marked atypia could lead to a malignant diagnosis. Pathologists, therefore, should exercise extreme caution in interpreting cases with 131I exposure.

Association between tinnitus and somatoform disorders.

Pathophysiological mechanisms are often unknown in patients suffering from "idiopathic" tinnitus, and the presence of other unexplained physical symptoms such as those seen in somatoform disorders can be assumed. This study investigates how often tinnitus exists in general medical out-patients with and without somatoform disorders. In an international study initiated by the World Health Organization (WHO), 1275 patients from 12 participating centers located in 11 different countries were examined by means of the WHO Somatoform Disorders Schedule. The overall prevalence of unexplained tinnitus was 11%; however, tinnitus was clearly more frequent among patients with somatization disorder (42%) or hypochondriacal disorder (27%). It was also more frequent than a great number of other symptoms considered to be typical of somatoform disorders. Tinnitus was also related to depression, anxiety, and to symptoms indicating autonomic arousal. Three possible conclusions are discussed: (i) tinnitus may be a somatoform symptom; (ii) the findings may indicate a substantial comorbidity of two different conditions; (iii) tinnitus and somatization may be linked through common mechanisms of arousal and somatic anxiety.

Medical services use by patients before and after detoxification from benzodiazepine dependence.

OBJECTIVE: The authors examined use of medical and mental health services before and after detoxification among a group of patients detoxified from benzodiazepines to see if the data suggested a reduction in service use and costs after detoxification, the so-called offset effect observed for treatment of alcohol and mental disorders. METHODS: Through a medical record review, information was collected about medical service use for patients aged 40 and older who were detoxified from benzodiazepines at Scott and White Clinic and Hospital between 1987 and 1991. RESULTS: Among the 76 patients, medical and mental health outpatient visits fell from an average rate of 25.4 visits per year before detoxification to 4.4 per year after detoxification. For the 44 patients with at least one inpatient stay besides the admission for detoxification, the mean number of inpatient days remained constant at three days per year before and after detoxification. CONCLUSIONS: Although a retrospective record review suffers from a range of limitations, the findings suggest that detoxification from benzodiazepines may be effective in reducing use of outpatient medical and mental health services and presumably in reducing costs of care.

Medically unexplained somatic symptoms in different cultures. A preliminary report from phase I of the World Health Organization International Study of Somatoform Disorders.

The World Health Organization has recently launched an international study of somatoform disorders in different cultures. Five centres representing distinct cultures participated in phase I of the project, the main objective of which was to test the cross-cultural applicability and reliability of instruments for the assessment of somatoform disorders. The analysis of the assessed somatic symptoms showed that various aches and pains in different parts of the body represented cross-culturally the most frequent symptoms for which there was no medical explanation. Such symptoms may indicate the presence of an underlying mental disorder but can also represent a means for culture-specific expression of psychosocial distress. This bears particular significance for health professionals in primary and general medical care, who are most likely to encounter patients presenting with multiple, persistent and medically unexplained somatic symptoms.

Increased rates of drug abuse and dependence after onset of mood or anxiety disorders in adolescence.

OBJECTIVE: The aim of the study was to examine the relationship of prevalence and age at onset of drug abuse and dependence to mood and anxiety disorders, using epidemiologic data. METHODS: Life-table analyses using data collected on 20,745 respondents in the National Institute of Mental Health's Epidemiologic Catchment Area surveys were used to calculate the hazard rate for developing drug disorders subsequent to adolescent-onset or adult-onset mood and anxiety disorders. RESULTS: For respondents with onset of a mood disorder during adolescence, the peak age for developing drug abuse and dependence occurs between 15 and 19 years; when the mood disorder begins in adulthood, the peak onset for drug disorders is delayed to between 25 and 29 years of age. Similar but less striking results are found for onset of drug abuse and dependence following either panic or obsessive-compulsive disorder. CONCLUSIONS: These findings highlight the need for future prospective studies of children and adolescents to date the onset of mental disorders and substance use disorders. If prospective studies can confirm the apparent pattern of substance use disorders occurring subsequent to mental disorders, prevention and treatment strategies for youth at risk should be developed.

Aspiration cytology of biphasic and monophasic synovial sarcoma. A report of two cases.

Two cases of synovial sarcoma diagnosed by aspiration cytology are described. A 15-year-old, athletic female presented with a tender midthigh mass clinically thought to be a hematoma. Aspiration cytology revealed numerous clusters of spindle cells admixed with small groups of epithelial cells. Cytokeratin and vimentin stains were positive in the epithelial and spindle components, respectively. Resection of the mass revealed a biphasic synovial sarcoma. Second, a 53-year-old male presented with a recurrent soft tissue mass 10 years after synovial sarcoma of the knee had been resected. Aspiration cytology revealed neoplastic spindle cells. Cytokeratin and vimentin preparations showed focal positivity. Resection revealed a predominantly monophasic synovial sarcoma. These cases demonstrate the utility of aspiration cytology in diagnosing both unsuspected and recurrent synovial sarcoma.

Disordered pathways of fibrin turnover in lung lavage of premature infants with respiratory distress syndrome.

Premature infants who have self-limited respiratory distress syndrome (RDS) rapidly improve, whereas infants with a complicated respiratory course are more likely to develop bronchopulmonary dysplasia (BPD), a chronic lung disorder that is the result of prolonged lung injury and impaired healing. The balance of competing activities of coagulation and fibrinolysis may contribute to the premature lung's response to acute injury and determine, in part, whether there is early resolution or protracted alveolar inflammation. To determine the relative activities of the coagulation and fibrinolytic pathways in neonatal lung injury, procoagulant (PC) and plasminogen activator (PA) activities were measured in undiluted cell-free lung lavage samples obtained serially over the first 28 days of life from 11 infants with self-limited RDS, 11 infants with evolving BPD, and 5 mechanically ventilated control infants without lung disease. Lung lavage from all three groups contained readily detectable procoagulant activity due mainly to the tissue factor-Factor VII complex. Plasminogen activator activity was relatively high in control lavage samples but depressed on the first day of life in the two groups of infants with lung disease: median, 0.3814 IU/ml (control); 0.0541 IU/ml (RDS); and 0.0454 IU/ml (BPD), p < 0.05 in each case compared with control. Two infants with severe lung disease had no detectable plasminogen activator activity in lung lavage on the first day of life. Depressed fibrinolytic activity correlated with severity of lung disease assessed radiographically and by pulmonary function measurements. Plasminogen activator activity was due to both tissue plasminogen activator and urokinase.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspiration cytology of heterotopic ossification. A case report.

Heterotopic ossification (myositis ossificans) is usually a posttraumatic reactive process involving new bone formation. This nonneoplastic process can be clinically and radiologically confused with osteosarcoma. A case of heterotopic ossification is reported in which cytologic material was obtained from a partially calcified thigh mass from a 17-year-old, athletic male. Aspiration cytology revealed numerous osteoclastic giant cells containing multiple plump nuclei. These cells were admixed in a benign-appearing stromal background composed of mature fibroblasts and were typified by elongated spindle cells. A small incisional biopsy showed new bone formation, osteoclasts, osteoblasts and fibroblasts consistent with maturing heterotopic ossification. Heterotopic ossification may be distinguished cytologically from osteosarcoma by the presence of numerous uniform benign stromal cells composed of mature fibroblasts and osteoclastic giant cells. The differential diagnosis may be more difficult in the early stages of this reactive and proliferative process. Adequate sampling of suspected heterotopic ossification by aspiration cytology may avoid surgery in a selected group of patients.

Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations.

Using data collected in the National Institute of Mental Health (Rockville, Md) Epidemiologic Catchment Area Program, we examined the proposed hypothesis that there has been a shift in major depression to younger ages at onset, or increased prevalence in younger age periods, for recent birth cohorts. Life-table survival methods were used to examine the hazard rates for major depression as well as for other specific mental disorders. The findings are consistent with a gradual shift to increased rates for major depression between the ages of 15 and 19 years for Epidemiologic Catchment Area respondents born more recently. The findings also suggest a similar shift for drug abuse/dependence; similar but less pronounced changes were found for alcohol abuse/dependence and obsessive-compulsive disorder. However, in this study, bipolar disorder, panic disorder, and phobias did not exhibit a consistent increase in onset at younger ages. Further research is required to determine if the shifts in major depression, drug abuse/dependence, and possibly alcohol abuse/dependence are linked. It is important to note that these shifts to adolescent onset are occurring when nearly half the 31 million Americans without health insurance are aged 24 years or younger.

Age at onset of selected mental disorders in five community populations.

Using data collected in the National Institute of Mental Health Epidemiologic Catchment Area Program, we examined the reported age at onset of selected mental disorders using life table survival methods. The examination of hazard rates suggests that adolescence and young adulthood are important periods for the development of unipolar major depression, bipolar illness, phobias, and drug and alcohol abuse/dependence. Although there are limitations in using cross-sectional data for this purpose, the findings suggest the need for more attention to the development of mental disorders in childhood and adolescence.