PURPOSE: Medically ill alcoholics are frequently encountered in medical practice, yet little is known about this subgroup of alcoholics. Anecdotal evidence suggests that current treatment methods may be ineffective in some of these patients, and that many of them resist referral to treatment programs. In this pilot study, we sought to characterize this group, in order to determine whether further research was indicated. BASIC PROCEDURES: In the Minneapolis VA Medical Center, we conducted a retrospective chart review of 61 alcoholics from 3 groups of alcohol-dependent patients: medical inpatients who accepted transfer to treatment, medical inpatients who refused transfer, and ambulatory patients requesting treatment. The groups were compared on demographic, physical, psychological, and laboratory characteristics, and on compliance with medical appointments. Most Important Findings: As might be expected, inpatients were older and sicker than ambulatory patients, but also demonstrated fewer nonmedical complications of alcoholism. On psychological testing, those who transferred were more likely to exhibit anxiety and depression, while the ambulatory patients were more antisocial. Inpatients who transferred differed from those who refused in having fewer previous treatments and less severe medical illness and in showing more compliance with medical recommendations in general. PRINCIPAL CONCLUSIONS: These findings raise the possibility that these groups may significantly differ from one another, and suggest that further research on the characteristics of medically ill alcoholics is indicated. Improved characterization could potentially lead to more effective treatment approaches.

Adult↗

PubMedDate not supplied

Patient and family reflections on the use of subcutaneous insulin to prevent diabetes: a retrospective evaluation from a pilot prevention trial.

A retrospective, semi-structured telephone interview was used to collect data from 28 of 31 families who participated in a pilot study testing subcutaneous insulin as a means to prevent or delay insulin-dependent diabetes mellitus (IDDM) onset. Interviews were conducted an average of 3 years after the initiation of the subcutaneous insulin protocol. Both the high-risk person (if > or = 8 years of age) and a family member (spouse or parent) were interviewed. Most participants reported that they were distressed to learn that they or a family member were at risk for IDDM, and families readily agreed to initiate subcutaneous insulin therapy. More children than adults reported insulin injections and blood glucose tests were "hard" or "very hard," but noncompliance was more common in adults. Of the high-risk participants interviewed, 58% of children and 100% of adults reported experiencing hypoglycemia, although episodes requiring someone else's assistance were rare, occurring in 38% of the children and 27% of the adults. Participants remained enthusiastic about trial participation; most favored screening programs to identify those at risk for IDDM, believed screening should be conducted regardless of age, believed subcutaneous insulin prevented or delayed IDDM onset, and would recommend subcutaneous insulin therapy to another high-risk individual. In addition, more than 40% of children, parents, and spouses reported that they would have benefited from access to a mental health professional at some point during the trial.

Adult↗

PubMedDate not supplied

Response to hypo- and hyperglycemia in adolescents with type I diabetes.

OBJECTIVE: To assess the appropriateness of adolescents' responses to hypo- and hyperglycemia and to examine the relationship of patient age, gender, diabetes duration, diabetes knowledge, parental supervision, and glycemic control to response appropriateness. METHODS: We assessed 125 adolescents' responses to daily episodes of hypo- and hyperglycemia by 24-hour recall interviews; responses were coded for type and appropriateness. RESULTS: Adolescents responded inappropriately to 38% of hypoglycemic and 29% of hyperglycemic episodes. Parental supervision of blood glucose testing did not increase the likelihood of an appropriate response; in the case of hyperglycemic episodes, it appeared to be counterproductive. Adolescents who responded inappropriately to hyperglycemia were also older but not different from those who responded appropriately by gender, disease duration, diabetes knowledge, or glycemic control. CONCLUSIONS: Health providers and family members may underestimate adolescents' difficulty managing hypo- and hyperglycemia appropriately. The presence of parental supervision does not ensure an appropriate response; parents may be particularly misinformed about the management of hyperglycemia.

Adolescent↗

PubMedDate not supplied

A new hepato-pancreato-renal disorder resembling tyrosinemia involving neuropathy and abnormal metabolism of polyunsaturated acids.

This report describes a new disorder resembling hereditary tyrosinemia (HT) but differing from it in several respects. Similarities include failure to thrive with hypoproteinemia, micronodular cirrhosis, alpha-fetoprotein positive hepatocellular carcinoma, renal Fanconi syndrome with renal tubular ectasia, hypermethioninemia, and hypoglycemia associated with islet cell hyperplasia. However, the tyrosine metabolic pathway was intact. Unique findings include optic atrophy, cerebellar degeneration, and exocrine pancreatic hypoplasia. Polyunsaturated fatty acid (PUFA) status was evaluated in the serum and liver. Initial PUFA profile to serum phospholipids revealed grossly elevated linoleic acid and subnormal linolenic acid. All PUFAs derived from these precursors were absent suggesting gross abnormalities in the utilization of these two essential fatty acids for synthesis of longer chain highly unsaturated structural PUFA. Analysis of liver phospholipids indicated that linoleic acid was lower and w3 and monenoic acids were higher than in the liver specimens from two cases of HT. The gross abnormalities in PUFA pattern, although perhaps secondary to another cause, represent serious structural and functional abnormalities of essential membrane lipids and potentially of eicosanoids derived from them.

Amino Acid Metabolism, Inborn Errors↗

PubMedDate not supplied

Group size, cage shelf level, and emotionality in non-obese diabetic mice: impact on onset and incidence of IDDM.

We hypothesized that differential housing, shown to influence emotionality and health in infectious and neoplastic disease, would influence onset/incidence of diabetes in an autoimmune animal model of insulin-dependent diabetes mellitus (IDDM). Non-obese diabetic mice were assigned to same-sex groups of one, five, or eight animals/cage, counterbalanced across shelf level by sex and group. During weekly urine glucose testing, presence of behaviors indicating emotional arousal was recorded. Sex, group, and shelf level affected emotionality: males, animals housed alone, and those on the top of the rack exhibited higher emotionality. Emotionality and shelf level predicted IDDM in females only. Delayed onset of IDDM was associated with high emotionality and with being housed on the top of the rack. Group size had no significant effect on IDDM. Emotionality may be a mediating factor in animals genetically predisposed to develop IDDM. This variable and cage shelf level should be incorporated into the design of studies in which IDDM is the outcome.

Animals↗

PubMedDate not supplied

Effects of carbamazepine on human chromosomes.

The effect of carbamazepine (CBZ) on human chromosomes was studied in an effort to determine its mutagenic potential. Analysis of chromosome breakage, sister chromatid exchanges (SCE), and cell cycle studies were performed in peripheral lymphocyte cultures. The in vivo studies failed to detect any significant increase of chromosome aberrations or SCE or any slowing of the cell cycle. A significant dose-dependent increase in chromosome aberrations but not in SCE was observed in the in vitro analyses. No correlation was observed between chromosome breaks and SCE in either the in vivo or in vitro studies. The negative in vivo results indicate an absence of detectable chromosome-damaging effects of CBZ used in monotherapy in human subjects.

Adult↗

PubMedDate not supplied

Family history of seizures in posttraumatic and alcohol-associated seizure disorders.

The potential role of genetic factors in the etiology of posttraumatic and alcohol-associated seizures was studied in 289 male patients with recurrent seizures and in 174 individuals who had never experienced a seizure. The incidence of seizures in first-degree relatives of probands was compared with that in relatives of unaffected individuals. Relatives of patients with alcohol-associated seizures had a rate ratio of 2.45 [95% confidence interval (CI) 1.41-4.25], whereas no excess incidence was noted among relatives of posttraumatic epilepsy patients (rate ratio 1.20, 0.64-2.25 CI). Relatives of probands with both antecedents showed an intermediate rate ratio of 1.72 (0.92-3.20 CI). Among probands with alcohol-associated seizures, the rate ratio of 2.05 for patients with alcohol-related seizures (i.e., spontaneously occurring seizures in association with chronic alcohol abuse) was slightly higher than that of 1.85 for probands with alcohol withdrawal seizures. Trauma severity had a slight impact on the incidence of affected relatives; patients with severe head injuries had a rate ratio of 0.73 and probands with milder trauma had a rate ratio of 0.99. The results indicate a limited, if any, role of genetic predisposition in development of posttraumatic seizures. Alcohol-related seizures, however, showed familial aggregation of unprovoked seizures, suggesting an involvement of genetic factors in the origin of such seizures.

Adult↗

PubMedDate not supplied

Necrotizing fasciitis of the head and neck: review of the literature and report of a case.

Necrotizing fasciitis is a rapidly spreading, life-threatening, bacterial disease. Mortality rates have been estimated to vary between 8.7% and 74%. Mortality depends on many factors, one of which is early recognition. Necrotizing fasciitis of dental origin has a low prevalence and as such presents diagnostic challenges for the dentist. The literature is reviewed, and a case history is presented.

Diagnosis, Differential↗

PubMedDate not supplied

Knowledge-based approaches to the maintenance of a large controlled medical terminology.

OBJECTIVE: Develop a knowledge-based representation for a controlled terminology of clinical information to facilitate creation, maintenance, and use of the terminology. DESIGN: The Medical Entities Dictionary (MED) is a semantic network, based on the Unified Medical Language System (UMLS), with a directed acyclic graph to represent multiple hierarchies. Terms from four hospital systems (laboratory, electrocardiography, medical records coding, and pharmacy) were added as nodes in the network. Additional knowledge about terms, added as semantic links, was used to assist in integration, harmonization, and automated classification of disparate terminologies. RESULTS: The MED contains 32,767 terms and is in active clinical use. Automated classification was successfully applied to terms for laboratory specimens, laboratory tests, and medications. One benefit of the approach has been the automated inclusion of medications into multiple pharmacologic and allergenic classes that were not present in the pharmacy system. Another benefit has been the reduction of maintenance efforts by 90%. CONCLUSION: The MED is a hybrid of terminology and knowledge. It provides domain coverage, synonymy, consistency of views, explicit relationships, and multiple classification while preventing redundancy, ambiguity (homonymy) and misclassification.

Computer Simulation↗

PubMedDate not supplied

A general natural-language text processor for clinical radiology.

OBJECTIVE: Development of a general natural-language processor that identifies clinical information in narrative reports and maps that information into a structured representation containing clinical terms. DESIGN: The natural-language processor provides three phases of processing, all of which are driven by different knowledge sources. The first phase performs the parsing. It identifies the structure of the text through use of a grammar that defines semantic patterns and a target form. The second phase, regularization, standardizes the terms in the initial target structure via a compositional mapping of multi-word phrases. The third phase, encoding, maps the terms to a controlled vocabulary. Radiology is the test domain for the processor and the target structure is a formal model for representing clinical information in that domain. MEASUREMENTS: The impression sections of 230 radiology reports were encoded by the processor. Results of an automated query of the resultant database for the occurrences of four diseases were compared with the analysis of a panel of three physicians to determine recall and precision. RESULTS: Without training specific to the four diseases, recall and precision of the system (combined effect of the processor and query generator) were 70% and 87%. Training of the query component increased recall to 85% without changing precision.

Diagnosis, Computer-Assisted↗

PubMedDate not supplied

A schema for representing medical language applied to clinical radiology.

OBJECTIVE: Develop a representational schema for clinical concepts and apply it to the task of encoding radiology reports of the chest. DESIGN: The schema was developed following a manual analysis of sample reports from the domain. The schema has two main components: the Medical Entities Dictionary (MED), which specifies the formal representation of the concepts in the domain and of their structures, and the natural-language processor, which specifies the linguistic expressions of the concepts. The schema was evaluated by applying it to a test set of 7,500 reports. Two-hundred reports from the test set were manually analyzed by a medical expert to determine the accuracy and success rate of the system. RESULTS: 82% of the 7,500 reports that contained relevant clinical information were successfully structured automatically. For the smaller set of 200 reports, 80% were structured successfully with an accuracy rate of 97%. CONCLUSIONS: The schema is a formal representation for clinical concepts in radiology reports, and provides domain coverage that is particularly well-suited for natural-language processing of radiology for use in a decision support system.

Decision Support Systems, Management↗

PubMedDate not supplied

Generic data modeling for clinical repositories.

OBJECTIVE: To construct a large-scale clinical repository that accurately captures a detailed understanding of the data vital to the process of health care and that provides highly efficient access to patient information for the users of a clinical information system. DESIGN: Conventional approaches to data modeling encourage the development of a highly specific data schema in order to capture as much information as possible about a given domain. In contrast, current database technology functions most effectively for clinical databases when a generic data schema is used. The technique of "generic data modeling" is presented as a method of reconciling these opposing views of clinical data, using formal operations to transform a detailed schema into a generic one. RESULTS: A complex schema consisting of hundreds of entities and representing a rich set of constraints about the patient care domain is transformed into a generic schema consisting of roughly two dozen tables. The resulting database design is efficient for patient-oriented queries and is highly flexible in adapting to the changing information needs of a health care institution, particularly changes involving the collection of new data elements. CONCLUSION: Conventional approaches to data modeling can be used to develop rich, complex models of clinical data that are useful for understanding and managing the process of patient care. Generic data modeling techniques can successfully transform a detailed design into an efficient generic design that is flexible enough to meet the needs of an operational clinical information system.

Hospital Information Systems↗

PubMedDate not supplied

A semantic lexicon for medical language processing.

OBJECTIVE: Construction of a resource that provides semantic information about words and phrases to facilitate the computer processing of medical narrative. DESIGN: Lexemes (words and word phrases) in the Specialist Lexicon were matched against strings in the 1997 Metathesaurus of the Unified Medical Language System (UMLS) developed by the National Library of Medicine. This yielded a "semantic lexicon," in which each lexeme is associated with one or more syntactic types, each of which can have one or more semantic types. The semantic lexicon was then used to assign semantic types to lexemes occurring in a corpus of discharge summaries (603,306 sentences). Lexical items with multiple semantic types were examined to determine whether some of the types could be eliminated, on the basis of usage in discharge summaries. A concordance program was used to find contrasting contexts for each lexeme that would reflect different semantic senses. Based on this evidence, semantic preference rules were developed to reduce the number of lexemes with multiple semantic types. RESULTS: Matching the Specialist Lexicon against the Metathesaurus produced a semantic lexicon with 75,711 lexical forms, 22,805 (30.1 percent) of which had two or more semantic types. Matching the Specialist Lexicon against one year's worth of discharge summaries identified 27,633 distinct lexical forms, 13,322 of which had at least one semantic type. This suggests that the Specialist Lexicon has about 79 percent coverage for syntactic information and 38 percent coverage for semantic information for discharge summaries. Of those lexemes in the corpus that had semantic types, 3,474 (12.6 percent) had two or more types. When semantic preference rules were applied to the semantic lexicon, the number of entries with multiple semantic types was reduced to 423 (1.5 percent). In the discharge summaries, occurrences of lexemes with multiple semantic types were reduced from 9.41 to 1.46 percent. CONCLUSION: Automatic methods can be used to construct a semantic lexicon from existing UMLS sources. This semantic information can aid natural language processing programs that analyze medical narrative, provided that lexemes with multiple semantic types are kept to a minimum. Semantic preference rules can be used to select semantic types that are appropriate to clinical reports. Further work is needed to increase the coverage of the semantic lexicon and to exploit contextual information when selecting semantic senses.

Humans↗

PubMedDate not supplied

Multicenter patient records research: security policies and tools.

The expanding health information infrastructure offers the promise of new medical knowledge drawn from patient records. Such promise will never be fulfilled, however, unless researchers first address policy issues regarding the rights and interests of both the patients and the institutions who hold their records. In this article, the authors analyze the interests of patients and institutions in light of public policy and institutional needs. They conclude that the multicenter study, with Institutional Review Board approval of each study at each site, protects the interests of both. "Anonymity" is no panacea, since patient records are so rich in information that they can never be truly anonymous. Researchers must earn and respect the trust of the public, as responsible stewards of facts about patients' lives. The authors find that computer security tools are needed to administer multicenter patient records studies and describe simple approaches that can be implemented using commercial database products.

Computer Security↗