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Medical record reporting system

Parthopratim Dutta Majumder, Avirupa Ghose, Meenakshi Chidambaram, Sudha K Ganesh, Jyotirmay Biswas
PURPOSE: To report the clinical profile of a series of necrotizing scleritis in an Indian population. METHODS: A retrospective medical record review of 27 consecutive patients with necrotizing scleritis. Patient demographics, ocular and systemic findings, treatment modalities, and visual outcome were recorded. RESULTS: There were 19 males and 8 females (31 eyes) with mean age at presentation of 49.5 years (range: 30-84 years). Underlying immunologically induced disorders was present in 37%...
October 20, 2016: Ocular Immunology and Inflammation
Theodore Pincus
An MDHAQ/RAPID3 (multidimensional health assessment questionnaire/routine assessment of patient index data) was developed from the HAQ over 25 years, based on observations made from completion by every patient (with all diagnoses) at every routine rheumatology visit since 1980. Modification of the HAQ was viewed as similar to improving a laboratory test, with a primary focus on clinical value for diagnosis, prognosis, and/or management, as well as feasibility for minimal effect on clinical workflow. Rigorous attention, was also directed to validity, reliability, other methodologic and technological considerations, but after clinical value and feasibility were established...
September 2016: Clinical and Experimental Rheumatology
Outi Laatikainen, Sami Sneck, Risto Bloigu, Minna Lahtinen, Timo Lauri, Miia Turpeinen
Adverse drug events (ADEs) are more likely to affect geriatric patients due to physiological changes occurring with aging. Even though this is an internationally recognized problem, similar research data in Finland is still lacking. The aim of this study was to determine the number of geriatric medication-related hospitalizations in the Finnish patient population and to discover the potential means of recognizing patients particularly at risk of ADEs. The study was conducted retrospectively from the 2014 emergency department patient records in Oulu University Hospital...
2016: Frontiers in Pharmacology
Rajkumar Bharatia, Manoj Chitale, Ganesh Narain Saxena, Raman Ganesh Kumar, Chikkalingaiah, Abhijit Trailokya, Kalpesh Dalvi, Suhas Talele
INTRODUCTION: Hypertension (HTN), being a major risk factor for cardiovascular diseases (CVDs), is an important issue of medical and public health. High blood pressure (BP) is ranked as the third most important risk factor for attributable burden of disease in south Asia (2010). Hypertension (HTN) exerts a substantial public health burden on cardiovascular health status and healthcare systems in India. Uncontrolled hypertension among adults with hypertension is associated with increased mortality...
July 2016: Journal of the Association of Physicians of India
Agne Ulyte, Nomeda Valeviciene, Darius Palionis, Simona Kundrotaite, Algirdas Tamosiunas
OBJECTIVE: In cardiac magnetic resonance imaging (CMR), incidental pathological findings are frequently found outside the investigated cardiovascular system. Some of these findings might have clinical implications. The aim of this study was to determine the prevalence of incidental extracardiac findings (ECF) in CMR and their clinical significance. METHODS: A total of 4165 CMR reports from 2009-2012 were retrospectively reviewed for ECF. Two hundred-twenty reports with ECF were found...
September 22, 2016: Hellenic Journal of Cardiology: HJC, Hellēnikē Kardiologikē Epitheōrēsē
Corey Butler, Suzanne Marsh, Joseph W Domitrovich, Jim Helmkamp
BACKGROUND: Wildland fire fighting is a high-risk occupation requiring considerable physical and psychological demands. Multiple agencies publish fatality summaries for wildland fire fighters; however, the reported number and types vary. At least five different surveillance systems capture deaths, each with varying case definitions and case inclusion/exclusion criteria. Four are population-level systems and one is case-based. System differences create challenges to accurately characterize fatalities...
October 18, 2016: Journal of Occupational and Environmental Hygiene
Yutaka Imai
It has been confirmed that clinical significance of home blood pressure measurements (HBPM) is higher than clinic BP measurements and ambulatory BP monitoring. However, several drawbacks of HBPM have also been mentioned, e.g. selection and reporting biases, difficulties of calculation of multiple measurements, difficulties of onsite judgement of numerous recordings, etc. Recent devices for HBPM incorporate memory function. This function can overcome such drawbacks of HBPM. These memorized data can transmit, storage, retrieve, be arithmetic and control, be judged based on algorithm and be got feedback...
September 2016: Journal of Hypertension
Barbara H Bardenheier, Jonathan Duffy, Susan K Duderstadt, Jay B Higgs, Michael P Keith, Patricia J Papadopoulos, William R Gilliland, Michael M McNeil
U.S. military personnel assigned to areas deemed to be at high risk for anthrax attack receive Anthrax Vaccine Adsorbed (AVA). Few cases of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been reported in persons who received AVA. Using a matched case-control study design, we assessed the relationship of RA and SLE with AVA vaccination using the Defense Medical Surveillance System. We identified potential cases using International Classification of Diseases, 9th Revision, Clinical Modification codes and confirmed cases with medical record review and rheumatologist adjudication...
October 2016: Military Medicine
Angel Paternina-Caicedo, Jezid Miranda, Ghada Bourjeily, Andrew Levinson, Carmelo Dueñas, Camilo Bello Muñoz, José A Rojas-Suarez
BACKGROUND: Every day, about 830 women die worldwide from preventable causes related to pregnancy and childbirth. Obstetric early-warning scores have been proposed as a potential tool to reduce maternal morbidity and mortality, based upon the identification of predetermined abnormal values in the vital signs or laboratory parameters, to generate a rapid and effective medical response. Several early-warning scores have been developed for obstetrical patients, but the majority are the result of a clinical consensus rather than statistical analyses of clinical outcome measures (i...
October 14, 2016: American Journal of Obstetrics and Gynecology
Kenzo J Koike, Jeffrey P Blice, Jan A Kylstra, Jonathan S Ralston, Sally E Self, Natasha M Ruth, Lucian V Del Priore
PURPOSE: To describe an unusual case of frosted branch angiitis that developed in a patient with acute onset systemic vasculitis possibly triggered by the antithyroid medication methimazole. METHODS: We conducted a thorough review of the medical records of a 16-year-old female patient who presented with frosted branch angiitis. During the initial hospital admission, the patient underwent an extensive systemic workup to determine the etiology of her disease and ophthalmologic testing including fundus photographs and fluorescein angiography...
October 5, 2016: Retinal Cases & Brief Reports
Tomohiro Sonoo, Satoshi Iwai, Ryota Inokuchi, Masataka Gunshin, Yoichi Kitsuta, Susumu Nakajima
Along with article-based checklists, structured template recording systems have been reported as useful to create more accurate clinical recording, but their contributions to the improvement of the quality of patient care have been controversial. An emergency department (ED) must manage many patients in a short time. Therefore, such a template might be especially useful, but few ED-based studies have examined such systems.A structured template produced according to widely used head injury guidelines was used by ED residents for head injury patients...
October 2016: Medicine (Baltimore)
William R Clark, Francesco Garzotto, Mauro Neri, Anna Lorenzin, Marta Zaccaria, Claudio Ronco
PURPOSE: Dialysis is a highly quantitative therapy involving large volumes of both clinical and technical data. While automated data collection has been implemented for chronic dialysis, this has not been done for acute kidney injury patients treated with continuous renal replacement therapy (CRRT). METHODS: After a brief review of the fundamental aspects of electronic medical records (EMRs), a new tool designed to provide clinicians with individualized CRRT treatment data is analyzed, with emphasis on its quality assurance capabilities...
October 10, 2016: International Journal of Artificial Organs
Emma Suggett, John Marriott
BACKGROUND: A number of methods exist for the risk assessment of hospital inpatients to determine the likelihood of patients experiencing drug-related problems (DRPs), including manual review of a patient's medication (medication reviews) and more complex electronic assessment using decision support alerts in electronic prescribing systems. A systematic review was conducted to determine the evidence base for potential risks associated with adult hospital inpatients that could not only lead to medication-related issues but might also be directly associated with pharmacist intervention...
September 2016: Drugs—Real World Outcomes
Cody S Olsen, Andrea M Thomas, Michael Singleton, Anna M Gaichas, Tracy J Smith, Gary A Smith, Justin Peng, Michael J Bauer, Ming Qu, Denise Yeager, Timothy Kerns, Cynthia Burch, Lawrence J Cook
BACKGROUND: Despite evidence that motorcycle helmets reduce morbidity and mortality, helmet laws and rates of helmet use vary by state in the U.S. METHODS: We pooled data from eleven states: five with universal laws requiring all motorcyclists to wear a helmet, and six with partial laws requiring only a subset of motorcyclists to wear a helmet. Data were combined in the Crash Outcome Data Evaluation System's General Use Model and included motorcycle crash records probabilistically linked to emergency department and inpatient discharges for years 2005-2008...
December 2016: Injury Epidemiology
Deborah Azrael, Alexander Mukamal, Amy P Cohen, David Gunnell, Catherine Barber, Matthew Miller
INTRODUCTION: Identifying the source and specific type of gas used in suicides is difficult using most data systems owing to limitations in ICD-10 coding. The National Violent Death Reporting System (NVDRS), with its rich collection of both coded and free-text variables, has the potential to overcome these limitations. This study used a multipronged approach to identify gas-specific suicides in NVDRS and to track the incidence of these suicides over time. METHODS: Using suicide cases from the 16 NVDRS states that participated throughout 2005-2012, free-text and code searches were conducted for four types of variables-incident narratives, coroner/medical examiner cause-of-death statements, cause-of-death codes, and substance names-to identify suicides by carbon monoxide, helium, hydrogen sulfide, and four other gases...
November 2016: American Journal of Preventive Medicine
Sarah P Justvig, Justine Li, Giuseppina Caravella, Minqin Chen, Hua Wang, Lisa A Benz Scott, Susmita Pati
While CHW interventions improve health outcomes, evidence identifying specific domains of CHW-delivered support resulting in positive outcomes is limited. Our goals were to identify domains of CHW-delivered support that assist families with adhering to recommended pediatric care; and, to identify predictors of successful completion of an enriched medical home intervention (EMHI) using trained CHWs making home visits to provide health education and support positive health behaviors. We performed a prospective descriptive study of 88 families participating in a protocol-based EMHI...
October 14, 2016: Journal of Community Health
Elizabeth H Dibble, David W Swenson, Cynthia Cobb, Timothy J Paul, Andrew E Karn, David C Portelli, Jonathan S Movson
The goal of this project was to create a system that was easy for radiologists to use and that could reliably identify, communicate, and track communication of important but non-urgent radiology findings to providers and patients. Prior to 2012, our workflow for communicating important non-urgent diagnostic imaging results was cumbersome, rarely used by our radiologists, and resulted in delays in report turnaround time. In 2012, we developed a new system to communicate important non-urgent findings (the RADiology CATegorization 3 (RADCAT-3) system) that was easy for radiologists to use and documented communication of results in the electronic medical record...
October 14, 2016: Emergency Radiology
Jasper H van Lieshout, Iris Bruland, Igor Fischer, Jan F Cornelius, Marcel A Kamp, Bernd Turowski, Angelo Tortora, Hans-Jakob Steiger, Athanasios K Petridis
BACKGROUND: Time has shown to be a relevant factor in the prognosis for a multitude of clinical conditions. The current analysis aimed to establish whether delayed admission to specialized care is a risk factor for increased mortality in case of high-grade aneurysmal subarachnoid hemorrhage. MATERIAL AND METHODS: Consecutive patients with aneurysmal subarachnoid hemorrhage were enrolled retrospectively if they had a World Federation of Neurological Surgeons Grading System grade of 5...
September 30, 2016: American Journal of Emergency Medicine
Simon Kocbek, Lawrence Cavedon, David Martinez, Christopher Bain, Chris Mac Manus, Gholamreza Haffari, Ingrid Zukerman, Karin Verspoor
OBJECTIVE: Text and data mining play an important role in obtaining insights from Health and Hospital Information Systems. This paper presents a text mining system for detecting admissions marked as positive for several diseases: Lung Cancer, Breast Cancer, Colon Cancer, Secondary Malignant Neoplasm of Respiratory and Digestive Organs, Multiple Myeloma and Malignant Plasma Cell Neoplasms, Pneumonia, and Pulmonary Embolism. We specifically examine the effect of linking multiple data sources on text classification performance...
October 11, 2016: Journal of Biomedical Informatics
Stephen Barnett, Joan Henderson, Adam Hodgkins, Christopher Harrison, Abhijeet Ghosh, Bridget Dijkmans-Hadley, Helena Britt, Andrew Bonney
BACKGROUND: Electronic medical data (EMD) from electronic health records of general practice computer systems have enormous research potential, yet many variables are unreliable. OBJECTIVE: The aim of this study was to compare selected data variables from general practice EMD with a reliable, representative national dataset (Bettering the Evaluation and Care of Health (BEACH)) in order to validate their use for primary care research. METHOD: EMD variables were compared with encounter data from the nationally representative BEACH program using χ (2) tests and robust 95% confidence intervals to test their validity (measure what they reportedly measure)...
October 12, 2016: HIM Journal
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