Toward best practice: leveraging the electronic patient record as a clinical data warehouse.

Automating clinical and administrative processes via an electronic patient record (EPR) gives clinicians the point-of-care tools they need to deliver better patient care. However, to improve clinical practice as a whole and then evaluate it, healthcare must go beyond basic automation and convert EPR data into aggregated, multidimensional information. Unfortunately, few EPR systems have the established, powerful analytical clinical data warehouses (CDWs) required for this conversion. This article describes how an organization can support best practice by leveraging a CDW that is fully integrated into its EPR and clinical decision support (CDS) system. The article (1) discusses the requirements for comprehensive CDS, including on-line analytical processing (OLAP) of data at both transactional and aggregate levels, (2) suggests that the transactional data acquired by an OLTP EPR system must be remodeled to support retrospective, population-based, aggregate analysis of those data, and (3) concludes that this aggregate analysis is best provided by a separate CDW system.

Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.

OBJECTIVE: To determine the effect of the Ischemic Heart Disease Shared Decision-Making Program (IHD SDP) an interactive videodisc designed to assist patients in the decision-making process involving treatment choices for ischemic heart disease, on patient decision-making. DESIGN: Randomized, controlled trial. SETTING: The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada. PARTICIPANTS: Two hundred forty ambulatory patients with MEASUREMENTS AND MAIN RESULTS: The primary outcome was patient satisfaction with the decision-making process. This was measured using the 12-item Decision-Making Process Questionnaire that was developed and validated in a randomized trial of the benign prostatic hyperplasia SDP. Secondary outcomes included patient knowledge (measured using 20 questions about knowledge deemed necessary for an informed treatment decision), treatment decision, patient-angiographer agreement on decision, and general health scores. Outcomes were measured at the time of treatment decision and/or at 6 months follow-up. Shared decision-making program scores were similar for the intervention and control group (71% and 70%, respectively; 95% confidence interval [CI] for 1% difference, -3% to 7%). The intervention group had higher knowledge scores (75% vs 62%; 95% CI for 13% difference, 8% to 18%). The intervention group chose to pursue revascularization less often (58% vs 75% for the controls; 95% CI for 17% difference, 4% to 31%). At 6 months, 52% of the intervention group and 66% of the controls had undergone revascularization (95% CI for 14% difference, 0% to 28%). General health and angina scores were not different between the groups at 6 months. Exposure to the IHD SDP resulted in more patient-angiographer disagreement about treatment decisions. CONCLUSIONS: There was no significant difference in satisfaction with decision-making process scores between the IHD SDP and usual practice groups. The IHD SDP patients were more knowledgeable, underwent less revascularization (interventional therapies), and demonstrated increased patient decision-making autonomy without apparent impact on quality of life.

Getting data out of the electronic patient record: critical steps in building a data warehouse for decision support.

Health care has taken advantage of computers to streamline many clinical and administrative processes. However, the potential of health care information technology as a source of data for clinical and administrative decision support has not been fully explored. This paper describes the process of developing on-line analytical processing (OLAP) capacity from data generated in an on-line transaction processing (OLTP) system (the electronic patient record). We discuss the steps used to evaluate the EPR system, retrieve the data, and create an analytical data warehouse accessible for analysis. We also summarize studies based on the data (lab re-engineering, practice variation in diagnostic decision-making and evaluation of a clinical alert). Besides producing a useful data warehouse, the process also increased understanding of organizational and cost considerations in purchasing OLAP tools. We discuss the limitations of our approach and ways in which these limitations can be addressed.

Renal cell carcinoma metastasizing to the thyroid gland.

Renal cell carcinoma represents 3% of all adult malignancies. Metastases occur most frequently in the bone and lung. Four cases of renal cell carcinoma metastasizing to the thyroid gland are described here. A literature review is presented and guidelines for the management of this rare condition are suggested.

Invasive ductal carcinoma of the breast metastatic to the endometrium.

Two patients with breast cancer which metastasized to the endometrium are described.

The immune response of foetal calves.

The immunological response of foetal calves to tetanus toxoid was investigated. Emphasis was placed on foetal immunocompetence and how this related to responses seen in adult cattle. The establishment of indwelling cannulas in the efferent prescapular lymphatic ducts and superficial veins of foetal calves allowed continual monitoring of cellular and humoral changes in efferent lymph and peripheral blood. Foetal calves from 195 to 253 days gestational age had the capacity to mount cell-mediated and humoral immune responses of similar character and magnitude as adult cattle to tetanus toxoid. Intravenous and subcutaneous routes of challenge with tetanus toxoid resulted in specific antibody production which peaked 26 to 31 days after vaccination. Significant tetanus toxoid-stimulated lymphocyte proliferation was present 4 to 6 weeks after vaccination with tetanus toxoid in both a foetus and an adult. After antigenic challenge lymphocytes remained the predominant cell type in efferent prescapular lymph of foetuses and cows while at the same time a marked shift to the left, characterised by band neutrophils and neutrophilic metamyelocytes occurred in peripheral blood. Lymph flow rate increased and cell concentration decreased after antigenic challenge.

Radial scars: a review of 30 cases.

Radial Scars/Complex Sclerosing Lesions are benign breast lesions that are seen more frequently now with the advent of screening mammography. These lesions need to be excised surgically in the absence of classical diagnostic features.

Spirometric measurements in healthy Sierra Leoneans.

Pulmonary Function Tests(PFTS) are useful in the diagnosis and management of respiratory disorders. They provide an objective and quantitative measure of some aspects of brocho-pulmonary function. For meaningful interpretation of PFTs, an individual's own previous baseline results compared with current results are preferred, but in the absence of such baseline values, standard normograms may be used. Since lung function values are influenced by genetic, environmental, nutritional, and several other factors, it is important for every laboratory to use normograms that reflect these important factors. The results presented here are the first baseline data on pulmonary function (VC, FVC, FEV1, and FEV%) in a wide cross-section of healthy Sierra Leoneans.

Prevalence of diabetes in rural and urban populations in southern Sierra Leone: a preliminary survey.

We conducted a preliminary community survey for diabetes in the Bo district of southern Sierra Leone. Five hundred and one subjects comprising 256 rural adults in two villages and 245 urban adults in Bo town were randomly selected and screened for diabetes using random capillary blood glucose according to WHO criteria. There were 6 diabetics, all in the urban area, giving a prevalence of 2.4% in the urban population, and 0% in the rural villages. The mean (s.d.) capillary random blood glucose (RBG) concentration was 5.7 +/- 1.7 mmol/l for the entire study population, while concentrations for the urban and rural populations were 5.8 +/- 2 and 5.5 +/- 1.4 mmol/l respectively (P > 0.05). RBG increased significantly with age. The mean (s.d.) body mass index (BMI) was 22.3 +/- 4.9 kg/m2 for the total population while those for the urban and rural populations were 23.0 +/- 5.8 and 21.6 +/- 3.6 respectively (P < 0.01). Only 5% of the population were obese, i.e. BMI > or = 30 kg/m2. Dietary habits were similar in both town and country. According to this survey, the prevalence of diabetes is very low in rural Sierra Leone, but urban areas may be experiencing increasing prevalence. Mechanisms for effective screening and promotion of proper diet and exercise must be incorporated into existing health services to prevent an escalation of diabetes in urban Sierra Leone.

The proliferative responses of lymphocytes from foetal calves and adult cattle.

This paper describes the proliferative responses of prescapular lymph lymphocytes and peripheral blood lymphocytes of foetal calves compared with cells of similar origin from adult cattle. Lymph lymphocytes were collected continuously by means of cannulation of efferent lymphatic ducts of the prescapular lymph node of foetal calves and adult cattle. Peripheral blood lymphocytes were collected from the foetus by means of cannulation of superficial veins of the foetus or of the umbilical vessels and from the jugular vein of adults. Foetal lymphocytes in one-way mixed lymphocyte culture stimulated and responded as well as adult lymphocytes. Foetal cells stimulated and responded more to cells from unrelated animals than to cells from their dam. Lymph lymphocytes from foetal calves between 188 and 253 days of gestation proliferated as well as adult lymphocytes and at a high level after stimulation with concanavalin A, phytohaemagglutinin and pokeweed mitogen. Response to stimulation with lipopolysaccharide, soybean agglutinin and wheat-germ agglutinin was variable but generally low and within the same range recorded by adult cells. Proliferation by foetal and adult whole-blood cultures was on occasions as high as that recorded by separated lymphocytes, even though fewer lymphocytes were initially present in the whole-blood cultures. Foetal lymph lymphocytes exhibited lower proliferative responses in autologous lymph plasma than in foetal calf serum or pooled foetal lymph plasma. There was no consistent depression of proliferation by culture medium supplements from pregnant animals. Rabbit serum consistently abrogated responses. Fetuin at final concentrations of greater than 2.5 mg/ml significantly depressed proliferation in foetal and adult lymphocytes from efferent lymph and peripheral blood.

The cellular response of lambs to Brucella ovis before and after birth.

The immunological response of lambs to Brucella ovis before and after birth was investigated. The establishment of indwelling cannulas in the efferent prescapular lymphatic ducts of foetal lambs allowed continual monitoring of the immune response of a single lymph node. Foetal lambs in the last trimester of pregnancy were shown to mount a strong cell-mediated immune response to B. ovis. Lymphocytes from the challenged lymph node stimulated with B. ovis in vitro usually first reacted significantly and had highest [3H]-thymidine incorporation between 4 and 6 days after primary and secondary challenge, whereas, lymphocytes from the unchallenged node did not exhibit significant [3H]-thymidine incorporation until some 24 h later. Lymphocytes from these lambs challenged as foetuses still exhibited significant [3H]-thymidine incorporation in response to B. ovis for 4 to 5 months after birth. The proportion of surface immunoglobulin-positive cells in efferent prescapular lymph of unchallenged lambs ranged from 0.5 to 2.0% but after B. ovis challenge this proportion ranged from 2.7 to 8.7% between 4 to 6 days after challenge. By 9 to 12 days after challenge, the proportion had declined to pre-challenge values.

Fetal lambs are depleted of IgM+ cells following a single injection of an anti-IgM antibody early in gestation.

B-cell depleted fetal sheep were created following a single injection of an anti-IgM monoclonal antibody early in gestation. Six sheep fetuses were given a single intraperitoneal injection of a monoclonal antibody directed against IgM at 63 days of gestation (gestation in sheep = 150 days). The fetuses were killed at 138-142 days of gestation and lymphoid tissues were collected for subsequent light microscopy and immunohistochemical examination. The ileal and jejunal Peyer's patch (PP) follicles in four of the six injected fetuses were markedly reduced in size. Cells in the rudimentary follicles of the ileal PP of these animals showed no reactivity for IgM and most were negative for CD45. The dome regions contained many T cells, which were predominantly CD8+ cells and included gamma delta T cells. The interfollicular areas of the PP of the markedly affected fetuses contained large populations of T cells. The spleen and lymph nodes were also markedly depleted of IgM+ cells and these tissues contained only a small, scattered population of weakly IgM+ cells. Follicular accumulations of IgM+ cells were absent. Large populations of T cells were present in the white pulp of the spleen and cortex of the lymph nodes. The liver did not contain IgM+ cells and the medulla of the thymus was depleted of IgM+ cells. The results of this study suggest that a surface IgM+ B-cell population is present in the sheep fetus at 63 days of gestation, which is essential for the colonization of the ileal PP and subsequent B-cell development.

Human and canine blastomycosis: A common source infection.

In fall 1993 a man and a dog developed blastomycosis after visiting an island off Bayfield Inlet, Georgian Bay, located near Parry Sound, Ontario. The man recovered but the dog died of blastomycosis. It was hypothesized that the common source of exposure was the island since the permanent residences of the two cases were in different cities. One further case of human infection, based on positive serology, and four additional cases of probable canine blastomycosis were identified. All cases had travelled to Bayfield Inlet during summer and early fall 1993. To the authors' knowledge this is the first Canadian report of a common source of infection of human and canine blastomycosis. This report also provides evidence for a new endemic area of blastomycosis infection.

Inpatient and post-discharge wound infections in general surgery.

The wound infection incidence during inpatient stay was compared with the post-discharge infection incidence for 1 month using audit data and a patient questionnaire. The true infection rate was found to be 20% compared with an apparent rate of 2.4% (P < 0.001). The study highlights the problems of postoperative monitoring in the context of shorter inpatient stays and fewer routine outpatient appointments.

Ontogeny of milky spots in the fetal lamb omentum.

Milky spots in the fetal lamb omentum were observed by light and electron microscopy under normal conditions and after intraperitoneal carbon injection in utero. Rudimentary milky spots first appeared as small aggregations of cells along capillaries of the omental branch of the right ruminal artery at 72 days of gestation. At 116 days of gestation, macrophages were detected immunohistochemically in the milky spots. At 125 days of gestation, T cells were detected in the milky spots, but B cells were absent. Under the conditions induced by intraperitoneal injection of carbon suspension, openings were observed between the omental mesothelial cells, and macrophage aggregations appeared on the surface of the omentum through the openings. At 148 days of gestation (newborn), the milky spots were noted as black spots because of aggregation of carbon laden macrophages. The present study demonstrates that milky spots are present at fixed sites in the fetal lamb omentum by the middle of the term, and that at birth the macrophages on the spots already possess phagocytotic ability. The fetus develops the ability to protect the peritoneal cavity by producing peritoneal macrophages from the milky spots in the greater omentum even in utero.

Retarded and excessive development of skin appendages in fetal lambs in response to thyroidectomy before wool follicle appearance.

The impact on wool follicles of development in an athyroid environment was studied in a series of twin fetal lambs by surgically thyroidectomizing one of each pair before the appearance of follicle buds and comparing development of epidermal appendages in it with their development in the normal co-twin. Thyroidectomy was undertaken at 51 to 54 days' gestation, i.e. after approximately one-third of the gestation period. Each treated fetus was then replaced in the uterus, allowing pregnancy to continue. Eight pairs of twins were removed at intervals from 67 to 122 days' gestation and skin samples from the thyroidectomized and the intact twins were compared. Micromorphometric examination of the samples was used to assess quantitatively the effects of thyroid deprivation on wool follicle development. In thyroidectomized fetuses there was a failure of keratinization in primary wool follicles, an absence of secondary follicles, a tendency to excessive follicular branching and sweat gland development, and a paucity of sebaceous gland formation. The density of wool follicles was substantially increased, but the mean cross-sectional area of these follicles was reduced. The effects of very early thyroidectomy imply that the thyroid plays a role in the stimulation and regulation of wool follicle differentiation. To test the reversibility of the effects observed in the skin of thyroidectomized fetuses, grafts from these animals were transplanted to normal, young fetal lambs. Subsequent examination of grafted skin revealed that complete keratinization had occurred but that none of the other abnormal features had been reversed.

Temporal trends in breast cancer surgery in Ontario: can one randomized trial make a difference?

OBJECTIVE: To assess the effect of a single randomized clinical trial, the National Surgical Adjuvant Breast Project (NSABP) B-06, on the surgical management of breast cancer in women. DESIGN: Retrospective cohort study. SETTING: All hospitals in Ontario. PATIENTS: A consecutive sample of 37,447 women with breast cancer newly diagnosed from Jan. 1, 1980, to Dec. 31, 1989, linked to a surgical procedure record in the Ontario Cancer Registry. MAIN OUTCOME MEASURE: The most invasive surgical procedure used within 90 days of diagnosis. RESULTS: Unilateral breast-ablative surgery (BAS) was performed in 57.3% of the women and breast-conserving surgery (BCS) in 31.6%. The annual rate of BAS declined from 77.5% in 1980 to 44.2% in 1989 and the rate of BCS rose from 12.5% in 1980 to 43.5% in 1989. The decline was linear from 1980 to 1984 and then accelerated significantly in 1985 (p < 0.0001), after the results of the NSABP B-06 trial were published. CONCLUSION: One randomized clinical trial can have an immediate and profound effect on medical practice.

Molecular characterization and outer membrane association of a Chlamydia trachomatis protein related to the hsp70 family of proteins.

One route by which Chlamydia trachomatis is internalized into host endometrial epithelial cells is receptor-mediated endocytosis. Although this implies an adhesin-receptor interaction exists, specific chlamydial surface molecules have not been identified. We are investigating potential adhesin molecules using an in vitro functional assay to select for chlamydial recombinant Escherichia coli expressing an adherent phenotype. We have previously shown that E. coli JM109(pPBW58) attaches to epithelial cells by a specific process paralleling C. trachomatis and expresses at least three plasmid-encoded proteins (18, 28, and 82 kDa; Schmiel, D. H., Knight, S. T., Raulston, J. E., Choong, J., Davis, C. H., and Wyrick, P. B. (1991) Infect. Immun. 59, 4001-4012). In this report, we demonstrate that (i) the 82-kDa protein is associated with the outer membrane of both E. coli JM109-(pPBW58) and C. trachomatis serovar E elementary bodies; (ii) the plasmid-encoded protein is identical to the native chlamydial protein by mass, charge, antigenicity, and partial proteolytic peptide profiles; (iii) a highly homologous protein is present in C. trachomatis biovariant lymphogranuloma venereum; (iv) the 82-kDa protein is not covalently linked by disulfide bonds to other protein species in either E. coli JM109(pPBW58) or C. trachomatis; (v) sequence analysis of the open reading frame indicates this protein is a relative of the heat shock 70 family of proteins; and (vi) the inferred amino acid sequence contains a contiguous 73-amino acid region having 51% identity with the extracellular sperm receptor binding domain in Strongylocentrosus purpuratus (Foltz, K. R., Partin, J. S., and Lennarz, W. J. (1993) Science 259, 1421-1425). The potential involvement of an hsp70 protein in attachment may provide new insight on adherence mechanisms by obligate intracellular pathogens.