Patient Clinical Record Research Articles

The Pediatric Emergency Care Applied Research Network Registry: A Multicenter Electronic Health Record Registry of Pediatric Emergency Care.

Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. A data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review. The Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly. The Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.

The administration of blood components: a British Society for Haematology Guideline.

The administration of blood components: a British Society for Haematology Guideline.

A review of implant provision for hypodontia patients within a Scottish referral centre.

Background Implant treatment to replace congenitally missing teeth often involves multidisciplinary input in a secondary care environment. High quality patient care requires an in-depth knowledge of treatment requirements.Aim This service review aimed to determine treatment needs, efficiency of service and outcomes achieved in hypodontia patients. It also aimed to determine any specific difficulties encountered in service provision, and suggest methods to overcome these.Methods Hypodontia patients in the Unit of Periodontics of the Scottish referral centre under consideration, who had implant placement and fixed restoration, or review completed over a 31 month period, were included. A standardised data collection form was developed and completed with reference to the patient's clinical record. Information was collected with regard to: the indication for implant treatment and its extent; the need for, complexity and duration of orthodontic treatment; the need for bone grafting and the techniques employed and indicators of implant success.Conclusion Implant survival and success rates were high for those patients reviewed. Incidence of biological complications compared very favourably with the literature.

Ubiquitous Pharmacogenomics (U-PGx): The Time for Implementation is Now. An Horizon2020 Program to Drive Pharmacogenomics into Clinical Practice.

Although the clinical validity of a number of pharmacogenetic markers is nowadays a matter of fact, and led authoritative scientific consortia as the Dutch Pharmacogenetic Working Group (DPWG) and the Clinical Pharmacogenomics Implementation Consortium (CPIC) to publish pharmacogenetic guidelines, the clinical implementation in real life remains challenging. Ubiquitous Pharmacogenomics (U-PGx) program is a coordinated effort that put together scientific and clinical expertise in the pharmacogenomic field, to implement the pre-emptive pharmacogenomic approach in the clinical practice in Europe, and to demonstrate its benefit in both patients' clinical outcome and quality of life, with an economic advantage for the healthcare system. The project is conceived as a clinical trial that will compare 4,000 patients, pre-emptively genotyped for a panel of pharmacogenes included in the DPWG guidelines, and treated accordingly, with 4,000 controls treated with the standard of care. All the genetic data will be prospectively collected and fully embedded into the patient's clinical record. An electronic clinical decision support system will be developed to alert physicians and pharmacists when a drug is being prescribed or dispensed to a patient with a risky genotype. U-PGx will test and harmonize this approach in seven healthcare environments (The Netherlands, Spain, UK, Italy, Austria, Greece, Slovenia) to set the basis for a future European healthcare system where an 'effective treatment optimization will be accessible to every European citizen' (www.upgx.eu).

Huntington disease, to have or not to have: That is the question – the importance of psychiatric symptoms

IntroductionHuntington's disease (HD) is an autosomal dominant inherited neurodegenerative disorder, beginning in adulthood. HD represents the majority of patients who present the triad of motor, cognitive and psychiatric symptoms. The last two may be early manifestations, but the clinical diagnosis is based on motor symptoms and a positive genetic test for CAG repeat extension. The remaining patients that are negative for the HD genetic mutation may have HD phenocopies.ObjectivesIllustrate the role of psychiatric assessment, discuss the psychiatric and behavioural manifestations, and management.AimsIllustrate the challenge of diagnosing HD in psychiatry.MethodsA literature search was performed on PubMed database. The patient clinical record was reviewed.ResultsWe report a case of a 49-year-old male with a family history of HD (mother, uncle, cousin). He was diagnosed with a psychotic disorder fifteen years ago, hospitalised twice and thereafter treated as an outpatient with fluphenazine long-acting injection. He was a symptomatic for ten years. During the last year, he started showing dysphoria, marked irritability, stammering, inappropriate behaviour, poorly structured paranoid delusions, mild cognitive impairment and lack of insight. This was correlated with the beginning of functional impairment, both professionally and socially. Further assessment was performed: neurological evaluation, head CT scan and the genetic test was negative. He is clinically stable under haloperidol long-acting injection.ConclusionsHD is a rare condition which is frequently under diagnosed, especially in early stages, due to lack of recognition of psychiatric symptoms. HD-like disorders should be considered if the clinical picture is obvious, but HD gene test result is negative.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Breathlessness and presentation to the emergency department: a survey and clinical record review

BackgroundBreathlessness is a frequently occurring symptom of cardiorespiratory conditions and is a common cause of emergency department presentation. The aim of this study was to estimate the prevalence of acute-on-chronic breathlessness as a cause for presentation to the major emergencies area of the emergency department.MethodsA prospective patient self-report survey and clinical record review of consecutive attendees to the major emergencies area of the emergency department in a single tertiary hospital between 12/5/14 and 29/5/14 was conducted. Eligible patients were clinically stable and had mental capacity to provide data.ResultsThere were 2,041 presentations during the study period, of whom 1,345 (66%) were eligible. There was a 90% survey response rate (1,212/1,345); 424/1,212 (35%) self-reported breathlessness most days over the past month of whom 245 gave breathlessness as a reason for this presentation. Therefore, the prevalence of acute-on-chronic breathlessness as a reason to present to the major emergencies area was 20.2% (245/1,212, 95% CI 17.9% to 22.5%). During this period there were 4,692 major and minor presentations; breathlessness was therefore a cause of at least 5.2% (245/4,692, 95% CI 4.6 to 5.9%) of all emergency department presentations.ConclusionsThis study found that one in five ambulance presentations to the ED were due to acute-on-chronic breathlessness. Most patients had non-malignant underlying conditions, had experienced considerable breathlessness for an extended period, had discussed breathlessness with their GP and presented out of daytime hours. Others were often involved in their decision to present. This represents clinically significant burden for patients, their family carers and the emergency health services.

Risk factors of osteonecrosis of the jaw after tooth extraction in osteoporotic patients on oral bisphosphonates.

PurposeThe aim of this study was to investigate the incidence of bisphosphonate-related osteonecrosis of the jaw (BRONJ) after tooth extraction in patients with osteoporosis on oral bisphosphonates in Korea and to evaluate local factors affecting the development of BRONJ.Materials and MethodsThe clinical records of 320 patients who underwent dental extraction while receiving oral bisphosphonates were reviewed. All patients had a healing period of more than 6 months following the extractions. Each patient's clinical record was used to assess the incidence of BRONJ; if BRONJ occurred, a further radiographic investigation was carried out to obtain a more definitive diagnosis. Various local factors including age, gender, extraction site, drug type, duration of administration, and C-terminal telopeptide (CTx) level were retrieved from the patients' clinical records for evaluating their effect on the incidence of BRONJ.ResultsAmong the 320 osteoporotic patients who underwent tooth extraction, 11 developed BRONJ, reflecting an incidence rate of 3.44%. Out of the local factors that may affect the incidence of BRONJ, gender, drug type, and CTx level showed no statistically significant effects, while statistically significant associations were found for age, extraction site, and duration of administration. The incidence of BRONJ increased with age, was greater in the mandible than the maxilla, and was associated with a duration of administration of more than 3 years.ConclusionTooth extraction in patients on oral bisphosphonates requires careful consideration of their age, the extraction site, and the duration of administration, and close postoperative follow-up should be carried out to facilitate effective early management.

Schizencephaly and psychosis: A case report

IntroductionSchizencephaly is a rare malformation of the central nervous system, a congenital disorder of cerebral cortical development resulting in the formation of abnormal unilateral or bilateral clefts in the cerebral hemispheres that extends from the pial surface to the ventricle. It often manifests with partial seizures, mental retardation and hemiparesis.ObjectiveTo illustrate a rare case of association between psychosis and schizencephaly and the implication of this association for understanding the biology of the psychosis.MethodsA literature search was performed on PubMed database using the key words schizencephaly, psychosis, brain diseases and retrieved papers were selected according to their relevance. The patient clinical record was reviewed.ResultsThe authors report a case of a 59-year-old male admitted into a psychiatric hospital with insomnia, disorganized behavior probably secondary to auditory hallucinations and mystic delusions. He also reported epilepsy and strabismus in his right eye since his childhood and right facial paresis. A head CT scan revealed a left deep cortico-ventricular parieto-occipital communication corresponding to schizencephaly.ConclusionsConsidering the theory that schizophrenia is associated with abnormal brain development, this case report may provide an example of a neurodevelopment abnormality that manifests as psychosis.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Psychiatric symptoms in Huntington's disease the importance of reliable information – A case report

IntroductionHuntington's Disease is an autosomal dominant neurodegenerative disease characterized by motor, psychiatric and cognitive symptoms. Irritability, affective disorders, apathy and psychosis are among the most frequent psychiatric symptoms and can predate the pre-clinical period.ObjectiveThe authors’ goal is to understand the complexity of Huntington's disease clinical presentation. Additionally, we present an illustrative clinical case.AimsTo convey the importance of collecting reliable information in order to make a proper diagnosis.MethodsA PubMed database review was performed using “Psychiatry”, “Psychiatric”, “Symptoms” and “Huntington's Disease” as keywords; retrieved papers were selected according to their relevance. The patient clinical record was reviewed.ResultsThe authors report a case of a 39-year-old woman, who was referred in 2014, to a psychiatrist because of depressive mood and suicidal ideation with two suicidal attempts in the past 5 years. However, she did not disclose her family history of Huntington's disease neither to her GP nor her psychiatrist. She never complied with the treatment plan and was admitted, in November, into a psychiatric unit because of subtle motor changes and apathy, which had resulted in personal neglect. The diagnosis could only be made after a family interview was held and the family medical history was revealed.ConclusionsCorroborative history from caregivers is of extreme importance in psychiatry. Early detection of symptoms can help mitigate the disease social impact. In our patient's case, by the time of proper diagnosis, she was estranged from her family and had endured distressing psychiatric symptoms without adequate treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Psychosis, cause or consequence of substance use disorder

IntroductionThe use of psychostimulants, such as amphetamines and cocaine in psychotic patients is 4 times more frequent than non-psychotic ones. It is believed that people with psychosis may use substances as a self-treatment for negative symptoms. However, early onset of substance use disorder can develop psychotic and/or negative symptoms, leading to confusion between primary or secondary psychosis.MethodSystematic review of the literature in English (PubMed) and patient's clinical record. Keywords: “Substance use disorder”; “psychosis”.Objectivesto highlight the importance of an adequate characterization of psychotic symptoms in patients with substance use disorder.CaseA 29-year-old man, with psychostimulants and cannabis abuse since adolescence and very short abstinence episodes. Later on, he developed paranoia symptoms that slightly improved once he decreased drugs dosage, but they were still present even on complete abstinence. Over the last year he has showed negative and psychotic symptoms that have been worsening with aggressive behavior during the last months, so he had to be hospitalized. During this period, he has been treated successfully with aripiprazol depot once monthly. His evolution has been positive, it has disappeared psychotic symptoms and paranoia, and after discharge he has managed to remain abstinent to psychostimulants.ConclusionsAdequate characterization of patients with psychotic symptoms and substance abuse is essential to determine whether the psychotic disorder is associated with primary or induced TUS. Therefore, it is essential a thorough clinical evaluation to make an accurate diagnosis and to draw an individualized treatment plan.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Pathoplastic Effects of Personality in Fibromyalgia

Introduction Fibromyalgia is a disorder characterized by chronic widespread pain and tenderness at palpation of specific points or associated symptoms of fatigue, un-refreshing sleep or cognitive dysfunction. Although his prevalence ranges from 2% to 6,4%, it remains a controversial and an exclusion diagnosis which causes are incompletely understood. Patients have been reported as being perfectionist, introspective, demanding and exhausting to manage. While such personality traits may appear to contribute to fibromyalgia symptoms, the links between them remain unclear. Objectives/Aims The author’s goal is to understand the complex role of personality traits in clinical presentation and management of patients with fibromyalgia. Additionally we present an illustrative clinical case. Methods A literature search was performed using the key words fibromyalgia, personality, trait psychology and retrieved papers were selected according to their relevance. The patient clinical record was reviewed. Results We discuss whether the personality traits result from or cause fibromyalgia symptoms and present a case of a 47 years old woman with fibromyalgia who presents to psychiatrist with a depression syndrome. The personality assessment revealed anxiety, immaturity and impulsivity. A multidisciplinary approach was made with rheumatology, psychiatry and psychology. The patient was treated with antidepressants, mood stabilizers, muscle relaxant and opioid analgesics, as well as psychoeducation. Eighteen months later, the patient remains with pain and concentration complaints, having improved sleep and functional capacity. Conclusions Personality might be involved in various aspects of chronic pain, as seen in fibromyalgia, and be involved in triggering, maintaining and exacerbation of the fibromyalgia’s process.

Prevalence and Difficulty Index Associated with the 3 rd Mandibular Molar Impaction among Malaysian Ethnicities: A Clinico- Radiographic Study

The mandibular third molars (3Mms) are the most common impacted teeth in the human dentition and their prevalence ranges from 27-68.8% in various parts of the world. The assessment of surgical difficulty of 3Mms extraction helps in better formulation of treatment plan by minimizing postoperative complications. The aim of this retrospective study was to investigate the prevalence and pattern of 3Mm impaction in patients between 20-44-year-old among Malaysian's ethnicities attending Oral Health Center/ SEGi University, Faculty of dentistry. This study reviewed 1249 orthopantomograms (OPGs) of subjects aged 20 to 44 years of three Malaysian ethnic groups. Of the study population 918 OPGs were considered for the study. Patient's details include age, gender and ethnicity were extracted from the patient's clinical record and all details related to impaction were obtained from patient's panoramic radiograph that was individually examined by two investigators. The data collected was statistically analysed using SPSS 16. This study found that Chinese female recorded the highest number of patients with "very difficult" category of impacted mandibular third molars. The most common age group involved was 20-24 years, mesioangular impaction, deep occlusal level and no ramus space for impacted mandibular third molars (3ms) were the most common findings observed. The present study suggests that predicting the level of difficulty preoperatively for impacted 3m surgery will help in formulating the better treatment plan, thereby minimizing the postoperative complication for the ultimate benefit of the patient.

A case of abdominal angina

Objective: In this case the authors want to enhance abdominal angina as an uncommon manifestation of a rare type of carcinoma, whose incidence has been increasing. Methods: Review of the patient's clinical record and Pubmed research using the keywords neuroendocrine carcinoma, abdominal angina, mesenteric ischemia, and intestinal obstruction. Results: A 61 year-old African woman arrived at the emergency department with abdominal colic pain in the inferior abdominal quadrants. She reported that in the last months this pain worsened after meals and relieved with fasting and, in the previous 3 days, she felt a sudden aggravation associated with constipation. The physical exam revealed no other alteration beside a mild painful abdomen. Laboratory findings consisted in leucopenia and a negative C reactive protein. Weeks before her hospital admission, she had undergone endoscopic exams that didn't reveal any significant changes. At the emergency department she underwent an abdominal CT which showed aspects compatible with mesenteric ischemia (though, inflammatory features couldn't be excluded) at the ileocecal and ascending colon level, with a coexisting mesenteric mass with 15 × 24 mm contacting directly, without apparent cleavage line, the superior mesenteric artery, which could correspond to an adenomegaly or neoplasic lesion. She was admitted to the Internal Medicine ward with the hypothesis of inflammatory bowel disease. Despite medication with mesalamine, the patient condition continued to degrade and evolved to intestinal obstruction. An emergent laparotomy was performed and several necrosed ileum loops were found twisting around the mesenteric mass. The histological exam of the surgical piece individualized a nodule corresponding to neuroendrocrine carcinoma. The immunocytochemical study was positive to chromogranin. The patient is nowadays in Oncology follow-up, which revealed negative for other neuroendrocrine tumors or metastasis. Conclusions: The neuroendrocrine tumours originate from the neuroendrocrine cells along the gastrointestinal, bronchopulmonary and genitourinary tract. They comprise 1.25% of overall malignancies and their prevalence has been increasing in the last years. Ileum neuroendocrine tumours have an incidence of 4.06/100,000.

Provision of Out-of-hospital Analgesia to Older Fallers With Suspected Fractures: Above Par, but Opportunities for Improvement Exist

Paramedics frequently attend older patients who have fallen and sustained suspected fractures, a population of patients who may be at risk of inadequate analgesic care. This prospective study aimed to describe the rate and effectiveness of analgesia administered by paramedics to older patients with suspected fractures secondary to falls and to identify predictive factors associated with provision of analgesia. A cohort of older patients aged greater than 65 years with suspected fall-related fractures was extracted from a database of 1,610 cases collected during a prospective, nonconsecutive observational study of older people who had fallen and received an ambulance response from October 1, 2010, through June 30, 2011. Fall-specific data, collected on scene by paramedics using a specially designed data form, were linked to patient clinical records and dispatch information. Descriptive analyses were performed to describe rates and effectiveness of analgesic administration, and multivariate logistic regression was conducted to identify factors associated with provision of analgesia. Of 1,610 patients in the observational study database, there were 333 patients identified as having suspected fractures, thus forming the study population. The mean (±SD) age was 82 (±8) years, and 75% were female. Suspected fractures of the hip were most common (42%). An initial pain score was recorded in 67% of cases, and the median initial pain severity was 8 of 10 (interquartile range [IQR] = 5 to 9). Overall, 60% received analgesia, and 80% of those received parenteral opiates. Intravenous (IV) morphine was most common (63%), followed by methoxyflurane (39%) and intranasal fentanyl (17%). Administration of oral analgesics was uncommon. Analgesia was considered to be clinically effective (≥30% relative reduction in pain severity) in 62% of cases. Patients with suspected hip fractures had greater odds of receiving analgesia compared to those with suspected fractures at other anatomical sites (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.17 to 6.32; p = 0.02). Compared to those with mild pain, the odds of receiving analgesia increased significantly for patients with moderate pain (OR = 6.5, 95% CI = 2.3 to 18.8; p < 0.0001) and severe pain (OR = 31.1, 95% CI = 9.9 to 97.6; p < 0.0001). In this population of older people who fell and sustained suspected fractures, two-thirds received paramedic-administered analgesia. The majority of patients received clinically effective analgesia, and the presence of a suspected hip fracture increased the likelihood of receiving pain relief.

Mercury-Associated Nephrotic Syndrome: A Case Report and Systematic Review of the Literature

Kidney injury from mercury is known to cause dose-related tubular dysfunction and idiosyncratic nephrotic syndrome according to various case reports. Motivated by a patient with subacute-onset nephrotic syndrome, histologic features of secondary focal segmental glomerulosclerosis, and concurrent mercury toxicity, we conducted a systematic review to explore renal histologic changes in patients with toxic mercury exposures and nephrotic syndrome. Data were extracted from a patient's clinical record. MEDLINE/Ovid was searched from 1950 to November 2010 using a prespecified search strategy. Two nephrology textbooks and the UpToDate online database also were searched. Inclusion criteria were studies of humans with nephrotic syndrome, nephrotic-range proteinuria, or kidney biopsy results reported. There were no exclusion criteria. We identified 27 other reports of 42 patients with nephrotic syndrome or nephrotic-range proteinuria. Of the 26 individuals, including our patient, who underwent kidney biopsy, histology showed glomerular disease in 21. Of these 20 biopsies, 4 showed minimal change disease and 15 showed membranous glomerulonephritis. Mercury exposure can lead to various glomerular lesions; we emphasize the importance of a careful occupational and dietary history in elucidating a cause for the undetermined nephrotic syndrome.

Digital Photography in Plastic Surgery

Sir:FigureWe read with great interest the article by Sanniec et al. entitled “Adherence to Photographic Standards: A Review of Plastic Surgeon Websites,”1 and we agree with the authors that photographs are essential in a plastic surgeon's practice. Although several articles have been published on this subject, medical publications/presentations and Web sites continue to appear that fail to satisfy clinical photography standards.2 These images are valuable for various purposes, including the following: creating models for preoperative planning, providing visual references during surgery, assessing surgical outcome, sharing data and experience with colleagues, communicating with patients to clarify their treatment plan, educating residents, and preparing presentations and publications. Moreover, photographs should be an integral part of the patient clinical record, in addition to informed consent, because they could represent one of the few elements of a physician's defense in medicolegal issues. In fact, today, most plastic surgeons, at some point in their career, have to address a complaint filed by a patient about their clinical performance, which may be followed by litigation. Because of the increasing importance of photographs, standardization according to well-established criteria is necessary to obtain significant and comparable images to be used in lawsuits. Very small variations can cause notable changes and may decrease markedly the value of clinical photography.3 Maintenance of constant camera settings, lighting, accurate positioning of subjects, no post–image acquisition changes using computer software, and use of identical views and patient preparation will significantly increase standardization.4 On this topic, in 2007, our group published an article in the journal Aesthetic Plastic Surgery entitled “Digital Photography in Plastic Surgery: How to Achieve Reasonable Standardization Outside a Photographic Studio.”5 In this article, on the basis of the medical literature and our own experience, we reported general criteria concerning patient preparation and camera setting and specific criteria for accurate image capture within different anatomical areas. The aim of our letter is to emphasize the importance of digital photography for plastic surgeons during medicolegal litigation; emphasize that plastic surgeons should use standardized photographic criteria; and raise awareness about some criteria, published in 2007 by our group, that we currently use in clinical practice. Use of strict digital photography guidelines that control all image characteristics will significantly enhance the potential of these images to objectively illustrate the plastic surgeon's work. Achille Aveta, M.D. Angela Filoni, M.D. Paolo Persichetti, M.D., Ph.D. Plastic Surgery Unit, University Campus Bio-Medico of Rome, Rome, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

P-449 - Prognostic factors regarding the treatment of dementia paralytica with malaria fever therapy: a historical cohort study

Dementia paralytica, a late neuropsychiatric complication of syphilis, was common in Europe at the beginning of the 20 th century. In the course of the subsequent century, the number of patients decreased dramatically, partly due to improved treatment options. One of the great therapeutic breakthroughs was the discovery of malaria fever therapy by Wagner von Jauregg. This retrospective cohort-study was designed to detect prognostic factors regarding the treatment of dementia paralytica with malaria fever therapy. Inpatients of the Vincent van Gogh psychiatric hospital in Venray were included in this study if they had a discharge diagnosis of dementia paralytica (general paralysis of the insane) and had been treated with malaria fever therapy in the period from 1907 to 1970. Patients were identified using annual reports and death registries from the hospital. Each patient's clinical record was reviewed for demographic, clinical, therapeutical and laboratory data. We measured survival after malaria fever therapy. Treatment response was categorized as: complete remission, incomplete remission but no hospitalization required, incomplete remission and permanent hospitalization required, unimproved or death during or shortly after treatment. The cause of death was classified as related or not related to dementia paralytica. Preliminary results suggest that 70 % of the patients were male. Many patients died within 2 months of hospitalisation, but some survived for more than 20 years. Further analysis is currently being done and definite results and conclusions will be presented at the meeting.

Cardiovascular risk profile of patients included in stent trials; a pooled analysis of individual patient data from randomised clinical trials: insights from 33 prospective stent trials in Europe

Few data document trends in cardiovascular (CV) risk-factors in patients with or without previous symptomatic CV disease. We assessed the prevalence and trends in (non) modifiable CV risk-factors, and the use of cardioprotective therapies in patients enrolled in coronary stent trials. This analysis included prospective data on 10,253 mainly European adults who were enrolled in 32 coronary stent studies between 1995 and 2006. Data was collected at the time of enrolment using a standardised patient clinical record form, and was analysed by considering three consecutive time periods: 1995-1997 (I), 1998-2002 (II) and 2003-2006 (III) rendering approximately equal numbers per period. Overall the proportion of active smokers remained constant (Period I to III: 28%, 27%, 21%, p=0.45), however the proportion increased in females below 50 years (about 2%/ year, R.RR: 1.20, P: 0.05 period III versus I). Prevalent diabetes increased (16%, 17%, 25%; p=0.029). The prevalence of a body-mass index (BMI) ≥25 kg/m² was high, but no trend was observed (69%, 68%, 70%; p=0.24). The proportion of patients with elevated blood pressure (i.e., ≥140/90 mmHg, in diabetes ≥130/80 mmHg) remained unchanged (55%, 50.%, 53%; p=0.22), despite an increase in the number of patients taking anti-hypertensive agents (84%, 89%, 90%; p=0.30). Conversely, the proportion of patients with elevated total cholesterol (i.e., ≥4.5 mmol/L) decreased (80%, 66%, 52%; p=0.002), which was consistent with the increase in patients taking lipid lowering drugs (32%, 62%, 69%; p=0.083). The portion of patients reaching therapeutic targets for blood lipids improved, but no improvement was seen in blood pressure control (p=0.29). There is an unmet clinical need in primary and secondary CV prevention in Europe. Patients requiring PCI are an important target population in whom lifestyle changes and aggressive secondary preventative measures should be aimed. Ultimately PCI should open the door towards optimising secondary prevention.

Multiple verification in computational modeling of bone pathologies

We introduce a model checking approach to diagnose the emerging of bone pathologies. The implementation of a new model of bone remodeling in PRISM has led to an interesting characterization of osteoporosis as a defective bone remodeling dynamics with respect to other bone pathologies. Our approach allows to derive three types of model checking-based diagnostic estimators. The first diagnostic measure focuses on the level of bone mineral density, which is currently used in medical practice. In addition, we have introduced a novel diagnostic estimator which uses the full patient clinical record, here simulated using the modeling framework. This estimator detects rapid (months) negative changes in bone mineral density. Independently of the actual bone mineral density, when the decrease occurs rapidly it is important to alarm the patient and monitor him/her more closely to detect insurgence of other bone co-morbidities. A third estimator takes into account the variance of the bone density, which could address the investigation of metabolic syndromes, diabetes and cancer. Our implementation could make use of different logical combinations of these statistical estimators and could incorporate other biomarkers for other systemic co-morbidities (for example diabetes and thalassemia). We are delighted to report that the combination of stochastic modeling with formal methods motivate new diagnostic framework for complex pathologies. In particular our approach takes into consideration important properties of biosystems such as multiscale and self-adaptiveness. The multi-diagnosis could be further expanded, inching towards the complexity of human diseases. Finally, we briefly introduce self-adaptiveness in formal methods which is a key property in the regulative mechanisms of biological systems and well known in other mathematical and engineering areas.

Children diagnosed with congenital cardiac malformations at the national university departments of pediatric cardiology: positive predictive values of data in the Danish National Patient Registry

Introduction:The present study was conducted to establish the positive predictive value of congenital cardiac malformation diagnoses registered in the Danish National Patient Registry (NPR), thereby exploring whether the NPR can serve as a valid tool for epidemiologic studies of congenital cardiac malformations.Materials and methods:The study population comprised every individual born from 2000 to 2008 who was registered in the NPR with a congenital cardiac malformation diagnosis and treated at one of the two national departments of pediatric cardiology. Positive predictive values were established comparing NPR information with the clinical record of each individual.Results:A total of 2952 patients with a total of 3536 diagnoses were eligible for validation. Review of their clinical records unveiled no patient without cardiac malformation. In 98% (98%–99%) of the cases, the NPR diagnosis could be found as the discharge diagnosis in the patient’s clinical record, and in 90% (89%–91%) of the cases the NPR diagnosis was considered a true reflection of the patient’s actual malformation.Conclusions:Our study verifies that the present study population retrieved from the NPR is a valid tool for epidemiological research within the topic of congenital cardiac malformations, given that the research question is not dependent on a fully established sensitivity of the NPR. Precautions should be made regarding cardiac malformations characterized by low prevalence or poor predictive values, and the reported validity should not be extrapolated beyond the study period.