Postpartum urinary retention after cesarean delivery.

OBJECTIVE: To investigate the incidence of postpartum urinary retention (PUR) after cesarean delivery and determine which obstetric factors contribute to this problem. METHOD: A prospective study recruited 605 pregnant women who had a cesarean delivery. Each patient's postvoid residual bladder volume (PVRBV) was estimated with an ultrasound scan after first micturition. The women were divided into 2 groups: PUR (PVRBV > or =150 mL) and normal. Patients' characteristics, obstetric parameters, and prevalence of lower urinary tract symptoms at 3 months postpartum were compared. RESULT: The overall incidence of PUR was 24.1%. The incidence of overt and covert PUR was 7.4% and 16.7%, respectively. Morphine-related postoperative analgesia, multiple pregnancy, and low body mass index were significantly associated with PUR. At 3-month follow-up, 5.0% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms. CONCLUSION: Our results revealed PUR was a common phenomenon in patients who had a cesarean delivery, and morphine-related postoperative analgesia was the main contributing factor.

Stroke complicating pregnancy and the puerperium.

Stroke complicating pregnancy and the puerperium in Taiwan and the comparison between Western and Eastern countries have not been well studied. We identified retrospectively 32 cases of stroke from 66,781 deliveries, including 21 intracranial hemorrhages and 11 cerebral infarctions from 1992 to 2004. The most common causes of intracranial hemorrhage were vascular anomaly (29%), pre-eclampsia/eclampsia (24%), undetermined (24%) and coagulopathy (19%). The most common causes of cerebral infarction were cardioembolism (36%), cerebral venous thrombosis (27%) and pre-eclampsia/eclampsia (18%). Perinatal adverse outcome included two stillbirths, nine premature deliveries and four abortions. The compiled results of previous studies and ours revealed that intracranial hemorrhage appeared to be slightly more common in Taiwan (43-69%) than in the Western countries (33-52%). The average maternal mortality rate was 17.8% (range 9-38) with 77.8% due to intracranial hemorrhage. The average incidence of stroke associated with pregnancy and the puerperium was 21.3 per 100,000 deliveries (range 8.9-67.1). Our study, different from the Western countries, showed that intracranial hemorrhage is slightly more common than cerebral infarction. Pre-eclampsia/eclampsia is an important cause of stroke, however, the possibility of cardioembolism in cerebral infarction and vascular anomaly in intracranial hemorrhage should be studied.

Pitfalls in the differential diagnosis of a pelvic cyst: lessons from a post-menopausal woman with bladder diverticulum.

We present a case of non-obstructive bladder diverticulum in a 75-year-old post-menopausal woman. An ovarian cyst was previously suspected, which resulted in a futile exploratory laparotomy without making any definite diagnosis, 1 year earlier. During this admission, transvaginal ultrasound-guided cyst aspiration was arranged to determine the nature of the presumed 'recurrent' cyst and to relieve the symptoms. Prior to cyst aspiration, up to 700 ml of urine through urinary catheterisation and the gradual disappearance of the 'cyst' alerted us to the possibility of a bladder diverticulum, which was later confirmed by retrograde cystography. This case illustrates the lessons that despite considerable researches having been done on enhancing sonographic accuracy, diagnosis based on imaging alone is likely to be associated with multiple pitfalls. Recognising the common pitfalls and integrating clinical information and alertness with ultrasonic features remains the mainstay of sonographic differential diagnosis.

Clinical inertia in the management of Type 2 diabetes metabolic risk factors.

AIMS: Delays in the initiation and intensification of medical therapy may be one reason patients with diabetes do not reach evidence-based goals for metabolic control. We assessed intensification of medical therapy over time, comparing the management of hyperglycaemia, hypertension, and hyperlipidaemia. METHODS: Prospective cohort study of 598 adults with Type 2 diabetes receiving primary care in an academic medical centre from May 1997 to April 1999. We assessed whether patients failing to achieve standard treatment goals for haemoglobin A1c (HbA1c), systolic blood pressure (SBP), or low density lipoprotein (LDL) cholesterol when last measured during 12 months (Year 1, 5/97-4/98) had increases in their corresponding medical regimen during the following 12 months (Year 2, 5/98-4/99). RESULTS: Among untreated patients in Year 1, seven of 12 (58%) of those above goal for HbA1c were initiated on medical therapy in Year 2, compared with 16 of 48 (34%) above SBP goal (P=0.02) and 26 of 115 (23%) above LDL cholesterol goal (P=0.02). Among patients on therapy and above goal, 124 of 244 (51%) patients with elevated HbA1c had their regimen increased in Year 2, compared with 85 of 282 (30%) with elevated SBP (P<0.001) and 22 of 79 (30%) with elevated LDL cholesterol (P<0.001). From Year 1 to Year 2 there was a decline in the overall proportion of patients above goal for LDL cholesterol (from 58% to 45%, P=0.002) but not for HbA1c or blood pressure. CONCLUSIONS: Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.

Sonographic diagnosis of a uterine defect in a pregnancy at 6 weeks' gestation with a history of curettage.

We present the early diagnosis and successful surgical treatment of uterine perforation. This was a rare case of cystic change of a uterine perforation, which was diagnosed by sonography during the first trimester of pregnancy. Surgical closure of the uterine wall defect was successful.

An XML-based format for guideline interchange and execution.

In building a general purpose guideline system based on GLIF--the GuideLine Interchange Format, we encountered limitations in the GLIF specification. These limitations, while not so apparent in the static version of guideline content, became readily so in the context of real world implementation, and pertain not only to GLIF-based systems, but generally as well. These limitations can be described as being in one of five categories. In this paper, we describe each of these categories in detail, and show how an execution environment based on XML data structures addresses these concerns.

Experience with an electronic health record for a homeless population.

A computerized electronic medical record (EMR) system using client-server architecture was designed and implemented by the Laboratory of Computer Science for use by the Boston Health Care for the Homeless Program (BHCHP) to meet the unique medical record needs of the homeless. For the past three years, this EMR has been used to assist providers in the delivery of health care to the homeless population of Boston. As the BHCHP has grown and technology improved, it is important to review what features of the EMR work, and to investigate what improvements can be made for the better delivery of care to the homeless, especially as we approach the next century.

Optimizing healthcare research data warehouse design through past COSTAR query analysis.

Over the past two years we have reviewed and implemented the specifications for a large relational database (a data warehouse) to find research cohorts from data similar to that contained within the clinical COSTAR database at the Massachusetts General Hospital. A review of 16 years of COSTAR research queries was conducted to determine the most common search strategies. These search strategies are relevant to the general research community, because they use the Medical Query Language (MQL) developed for the COSTAR M database which is extremely flexible (much more so than SQL) and allows searches by coded fields, text reports, and laboratory values in a completely ad hoc fashion. By reviewing these search strategies, we were able to obtain user specifications for a research oriented healthcare data warehouse that could support 90% of the queries. The data warehouse was implemented in a relational database using the star schema, allowing for highly optimized analytical processing. This allowed queries that performed slowly in the M database to be performed very rapidly in the relational database. It also allowed the data warehouse to scale effectively.

Using the extensible markup language (XML) in automated clinical practice guidelines.

Much work has been done in the area of web-based clinical practice guidelines. Issues such as representation, description, architectures, and implementation have been explored previously. Most if not all of these web-based applications rely exclusively on HTML, the HyperText Markup Language. In the process of prototyping a guideline service to be used in a diabetes operations improvement project, we developed a model for a guideline engine that makes use of the Extensible Markup Language (XML), both as an interface to the engine and as a vehicle for delivering structured guideline content. We feel that XML may offer advantages in implementing guideline services that are difficult (if not impossible) to accomplish with HTML alone.

An XML portable chart format.

The clinical chart remains the fundamental record of outpatient clinical care. As this information migrates to electronic form, there is an opportunity to create standard formats for transmitting these charts. This paper describes work toward a Portable Chart Format (PCF) that can represent the relevant aspects of an outpatient chart. The main goal of the format is to provide a packaging medium for outpatient clinical charts in a transfer of care scenario. A secondary goal is to support the aggregation of comparable clinical data for outcomes analysis. The syntax used for PCF is Extended Markup Language (XML), a W3C standard. The structure of the PCF is based on a clinically relevant view of the data. The data definitions and nomenclature used are based primarily on existing clinical standards.

Components of the optimal ambulatory care computing environment.

We present here a framework of core components of an ambulatory care computing environment, based on clinical and functional needs and workflow scenarios. We have established this framework through the use of two study devices: a vision of the clinical office of the future, and a survey of possible computer applications, both designed to help clinicians and practice directors communicate their information needs to systems designers. Clinicians prioritize applications based on strategic and practice goals: support for clinical users' workflow, improved quality of care, reduced cost of care, and the ability to measure performance and status. By reorganizing the needed functionality from a clinical viewpoint into a technical viewpoint, we are able to identify core information components for systems design. Based on this analysis, information needs in the ambulatory environment can be divided into five primary functions: patient data retrieval, documentation, communication, knowledge resources, and aggregate reporting. Three other fundamental processes--knowledge-based interventions, information integration, and confidentiality--run through all of these front-line functions. Component applications and data structures built with this framework in mind will afford a maximum combination of functionality and flexibility to handle future changes in the clinical environment.

Component architecture for web based EMR applications.

The World Wide Web provides the means for the collation and display of disseminated clinical information of use to the healthcare provider. However, the heterogeneous nature of clinical data storage and formats makes it very difficult for the physician to use one consistent client application to view and manipulate information. Similarly, developers are faced with a multitude of possibilities when creating interfaces for their users. A single patients records may be distributed over a number of different record keeping systems, and/or a physician may see patients whose individual records are stored at different sites. Our goal is to provide the healthcare worker with a consistent application interface independent of the parent database and at the same time allow developers the opportunity to customize the GUI in a well controlled, stable application environment.

A software architecture to support a large-scale, multi-tier clinical information system.

A robust software architecture is necessary to support a large-scale multi-tier clinical information system. This paper describes our mechanism for enterprise distribution of applications and support files, the consolidation of data-access functions and system utilities stored on the data access tier, and an application framework which implements a coherent clinical computing environment. The software architecture and systems described in this paper have been robust through pilot testing of our applications at Massachusetts General Hospital.

Maintaining the confidentiality of medical records shared over the Internet and the World Wide Web.

The Boston Electronic Medical Record Collaborative is working to develop a system that will use the World Wide Web to transfer computer-based patient information to clinicians in emergency departments. Maintaining adequate confidentiality of these records while still facilitating patient care is paramount to this effort. This paper describes an explicit protocol that would make it possible to electronically identify patients and providers, secure permission for release of records, and track information that is transmitted. It is hoped that other, similar efforts now underway will be able to use and build on this model. Comment on this proposal is invited from all parties with an interest in confidentiality. The system will be used only with "scrubbed" data-data from which all identifiers have been removed-until it is generally agreed that the confidentiality methods proposed here are appropriate and sufficient.

"Just-in-time" clinical information.

The just-in-time (JIT) model originated in the manufacturing industry as a way to manage parts inventories process so that specific components could be made available at the appropriate times (that is, "just in time"). This JIT model can be applied to the management of clinical information inventories, so that clinicians can have more immediate access to the most current and relevant information at the time they most need it--when making clinical care decisions. The authors discuss traditional modes of managing clinical information, and then describe how a new, JIT model may be developed and implemented. They describe three modes of clinician-information interactions that a JIT model might employ, the scope of information that may be made available in a JIT model (global information or local, case-specific information), and the challenges posed by the implementation of such an information-access model. Finally, they discuss how JIT information access may change how physicians practice medicine, various ways JIT information may be delivered, and concerns about the trustworthiness of electronically published and accessed information resources.

Maintaining the integrity of a Web-based medical vocabulary glossary.

Medical vocabulary databases are vital components of electronic medical record (EMR) systems. While their performance and efficiency has been extensively explored by many authors, few have dealt with the maintenance of their semantic integrity. Clinicians' preference for an optimistic system has introduced a need for monitoring and filtering proposed additions to the vocabulary tables. We propose the use of batch processing and memo-posting as means of implementing a World-Wide-Web-based Controlled Vocabulary Glossary as a monitored optimistic system.

Design considerations in migrating an obstetrics clinical record to the Web.

Recently the American College of Obstetricians and Gynecologists (ACOG) embarked on an effort to promote the development of nationally networked obstetrical records. The Laboratory of Computer Science (LCS) is collaborating with them to help achieve this goal through the development of a web-based prototype of an electronic medical record (EMR) which would allow the entry and display of typical clinical information for the obstetric patient. The process of porting a stand alone application to the web environment necessitated the development of a robust software scheme that could exploit the strengths of Web-based technologies and avoid some of the drawbacks inherent in a stateless environment.

Preserving context in a multi-tasking clinical environment: a pilot implementation.

The Partners Clinical Application Suite (CAS) is a multi-tasking software architecture that facilitates the development, deployment, and use of advanced clinical information management applications. This paper describes 1) a software shell in which clinical applications run; 2) an application programming interface (API); and 3) development of a set of "Look & Feel" guidelines. Through its emphasis on support for multi-tasking and application interoperability, CAS facilitates preservation of the user's context.

Sharing electronic medical records across multiple heterogeneous and competing institutions.

Most early reports of implemented World-Wide Web (W3) medical record systems describe single institution architectures. We describe W3-EMRS, a multi-institutional architecture, and its implementation. Thorny problems in data sharing underlined by the W3-EMRS project are reviewed.