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Introduction: Electronic health records (EHR) comprehend structured and unstructured data, that are usually time dependent, enabling the use of timelines. However, it is often difficult to display all data without inducing information overload. In both clinical usual care and medical research, users should be able to quickly find relevant information, with minimal cognitive overhead. Our goal was to devise simple visualization techniques for handling medical data in both contexts., Methods: An abstraction layer for structured EHR data was devised after an informal literature review and discussions between authors. The "Heimdall" prototype was developed. Two experts evaluated the tool by answering 5 questions on 24 clinical cases., Results: Temporal data was abstracted in three simple types: events, states and measures, with appropriate visual representations for each type. Heimdall can load and display complex heterogeneous structured temporal data in a straightforward way. The main view can display events, states and measures along a shared timeline. Users can summarize data using temporal, hierarchical compression and filters. Default and custom views can be used to work in problem- oriented ways. The evaluation found conclusive results., Conclusion: The "Heimdall" prototype provides a comprehensive and efficient graphical interface for EHR data visualization. It is open source, can be used with an R package, and is available at https://koromix.dev/files/R.

In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care., (Copyright © 2019 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.)

Background: The community pharmacist is a key player in medication reviews of older outpatients. However, it is not always clear which individuals require a medication review. The objective of the present study was to identify high-priority older patients for intervention by a community pharmacist., Methods: As part of their final-year placement in a community pharmacy, pharmacy students conducted 10 interviews each with older adults (aged 65 or over) taking at least five medications daily. The student interviewer also offered to examine the patient's home medicine cabinet. An interview guide was developed by an expert group to assess the difficulties in managing and taking medications encountered by older patients., Results: The 141 students interviewed a total of 1370 patients (mean age: 81.5; mean number of medications taken daily: 9.3). Of the 1370 interviews, 743 (54.2%) were performed in the patient's home, and thus also included an examination of the home medicine cabinet. Adverse events were reported by 566 (42.0%) patients. A total of 378 patients (27.6%) reported difficulties in preparing, administering and/or swallowing medications. The inspections of medicine cabinets identified a variety of shortcomings: poorly located cabinets (in 15.0% of inspections), medication storage problems (21.7%), expired medications (40.7%), potentially inappropriate medications (15.0%), several different generic versions of the same drug (19.9%), and redundant medications (20.4%)., Conclusions: In a community pharmacy setting, high-priority older patients for intervention by a community pharmacist can be identified by asking simple questions about difficulties in managing, administering, taking or storing medications.

Several definitions of chronic diseases exist. The objective is to reuse a nationwide medical-administrative database (PMSI) to estimate the lifespan of diagnostic codes, hence the chronicity of the corresponding diseases. We analyzed 162 million inpatient stays from 2008 to 2014, and estimate the lifespan of every ICD-10 code for every patient, identified by a unique imprint. We calculated 200 indicators for different time and survival values, and selected the ones that maximized the area under the ROC curve (AUC) drawn by comparison against 4 chronic disease classifications: CCI, ALD, result from the analysis of ICD-10 labels, and a handmade list. The best indicator was the time to reach a survival of 4.5%. It enables to get the following AUC: 78.9% compared with CCI, 90.3% compared with ALD, 75.1% compared with labels analysis, and 91.5% compared with the handmade list. This indicator enables to classify 23,349 ICD-10 codes from "most chronic" to "most acute". The 100 most chronic codes are listed.

Background: Comparisons of clinical trial findings in systematic reviews can be hindered by the heterogeneity of the outcomes reported. Moreover, the outcomes that matter most to patients might be underreported. A core outcome set can address these issues, as it defines a minimum set of outcomes that should be reported in all clinical trials in a particular area of research. The objective in this study was to develop a core outcome set for clinical trials of medication review in multi-morbid older patients with polypharmacy., Methods: Firstly, eligible outcomes were identified through a systematic review of trials of medication review in older patients (≥65 years) and interviews with 15 older patients. Secondly, an international three-round Delphi survey in four countries involving patients, healthcare professionals, and experts was conducted to validate outcomes to be included in the core outcome set. Consensus meetings were conducted to validate the results., Results: Of the 164 participants invited to take part in the Delphi survey, 150 completed Round 1, including 55 patients or family caregivers, 55 healthcare professionals, and 40 experts. A total of 129 participants completed all three rounds. Sixty-four eligible outcomes were extracted from 47 articles, 32 clinical trial protocols, and patient interviews. Thirty outcomes were removed and one added after Round 1, 18 outcomes were removed after Round 2, and seven after Round 3. Results were discussed during consensus meetings. Consensus was reached on seven outcomes, which constitute the core outcome set: drug-related hospital admissions; drug overuse; drug underuse; potentially inappropriate medications; clinically significant drug-drug interactions; health-related quality of life; pain relief., Conclusions: We developed a core outcome set of seven outcomes which should be used in future trials of medication review in multi-morbid older patients with polypharmacy.

Background Although many anticholinergics are inappropriate in older patients, the prescription of these drugs in a hospital setting has not been extensively studied. Objective To describe prescriptions of anticholinergic drugs in terms of frequency, at risk situations and constipation in hospitalized, older adults. Setting Using a database from a French general hospital (period 2009-2013), we extracted information on 14,090 hospital stays by patients aged 75 and over. Methods Anticholinergic drug prescriptions were automatically detected, with a focus on prescriptions in three well-known at-risk situations: falls, dementia, and benign prostatic hyperplasia. Cases of constipation that might have been causally related to the administration of anticholinergic drugs were screened for and reviewed. Main outcome measure Prescriptions with a high associated risk of anticholinergic related adverse reactions. Results Administration of an anticholinergic drug was detected in 1412 (10.0%) of the hospital stays by older patients. At-risk situations were identified in 413 (36.5%) of these stays: 137 (9.7%) for falls, 243 (17.2%) for dementia, and 114 (8.1%) for benign prostatic hyperplasia; 78 (18.9%) of these 413 stays featured a combination of two or three at-risk situations. Cases of constipation induced by anticholinergic drug administration were identified in 188 (13.3%) patient stays by using validated adjudication rules for adverse drug reactions: 85 and 103 cases were respectively evaluated as "possible" or "probable" adverse drug reactions. Conclusions Anticholinergic drugs prescription was found in 10.0% of hospitalized, older patients. More than one third of these prescriptions occurred in at-risk situations and more than one in ten prescriptions induced constipation.

Potentially inappropriate prescriptions (PIPs) of antibiotics (antibiotic-PIPs) are generally detected by applying implicit definitions based on expert opinion. Explicit definitions are less frequently used, even though this approach would enable the automated detection of antibiotic-PIPs in electronic health records. Here, explicit definitions of antibiotic-PIPs used in studies of older adults were systematically reviewed. The MEDLINE ® , Scopus ® and Web of Science TM core collection databases were searched with a combination of three terms and their synonyms: 'potentially inappropriate prescription' AND 'antibiotic treatment' AND 'older patients'. Following standardised selection of publications, explicit definitions of antibiotic-PIPs were extracted and were classified into infectious diseases domains and subdomains. A total of 600 search queries identified 4270 records, 93 of which were selected for review. A total of 160 mentions of antibiotic-PIPs were found, corresponding to 62 distinct definitions in 19 infectious diseases domains. Nearly one-half of the definitions were related to upper respiratory tract infections (n = 11 definitions; 17.7%), lower respiratory tract infections (n = 8; 12.9%) and drug-drug interactions (n = 11; 17.7%). Almost 75% of definitions (n = 46) were mentioned in a single study only. Only three definitions concerned critically important antibiotics such as third-generation cephalosporins and fluoroquinolones. This systematic review identified 62 explicit definitions of antibiotic-PIPs. Most of the definitions were not found in more than one study and they varied in the degree of precision. We advocate the implementation of an expert consensus on explicit definitions of antibiotic-PIPs that correspond to today's challenges in public health., (Copyright © 2017 Elsevier B.V. and International Society of Chemotherapy. All rights reserved.)

Background: Several studies have shown that the prescription of antiplatelet therapy (APT) is associated with an increased risk of oral anticoagulant (OAC) underuse in patients aged 75 years and over with atrial fibrillation (AF). An associated atheromatous disease may be the underlying reason for APT prescription. The objective of the study was to determine whether the association between underuse of OAC and APT prescription was explained by the presence of an atheromatous disease., Methods and Results: We performed a retrospective, observational, single-centre study between 2009 and 2013 based on administrative data. Patients aged 75 years and over with non-valvular AF were identified in a database of 72,090 hospital stays. Prescriptions of anti-thrombotic medications and their association with the presence of atheromatous disease were evaluated by the mean of a logistic regression. A total of 2034 hospital stays were included (mean age 84.3 ± 5.2 years). The overall prevalence of known atheromatous disease was 25.9%. OAC underuse was observed in 58.5% of the stays. In multivariable analysis, the prescription of an APT was associated with an increased risk of OAC underuse [odds ratio (OR) 6.85; 95% confidence interval (CI) 5.50-8.58], independently of the presence of a concomitant known atheromatous disease (OR 0.78; 95% CI 0.60-1.01). Among the 692 stays with APT monotherapy (34.0%), 232 (33.5%) displayed an atheromatous disease., Conclusions: The underuse of OAC is associated with the prescription of APT in older patients with AF, regardless of the presence or absence of known atheromatous disease. Our results suggest that APT is often inappropriately prescribed instead of OAC.

Background: Although many researchers in the field of health economics and quality of care compare the length of stay (LOS) in two inpatient samples, they often fail to check whether the sample meets the assumptions made by their chosen statistical test. In fact, LOS data show a highly right-skewed, discrete distribution in which most of the observations are tied; this violates the assumptions of most statistical tests., Objectives: To estimate the type I and type II errors associated with the application of 12 different statistical tests to a series of LOS samples., Methods: The LOS distribution was extracted from an exhaustive French national database of inpatient stays. The type I error was estimated using 19 sample sizes and 1,000,000 simulations per sample. The type II error was estimated in three alternative scenarios. For each test, the type I and type II errors were plotted as a function of the sample size., Results: Gamma regression with log link, the log rank test, median regression, Poisson regression, and Weibull survival analysis presented an unacceptably high type I error. In contrast, the Student standard t test, linear regression with log link, and the Cox models had an acceptable type I error but low power., Conclusions: When comparing the LOS for two balanced inpatient samples, the Student t test with logarithmic or rank transformation, the Wilcoxon test, and the Kruskal-Wallis test are the only methods with an acceptable type I error and high power., (Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Background: The significant risk of adverse events following medical procedures supports a clinical epidemiological approach based on the analyses of collections of electronic medical records. Data analytical tools might help clinical epidemiologists develop more appropriate case-crossover designs for monitoring patient safety., Objective: To develop and assess the methodological quality of an interactive tool for use by clinical epidemiologists to systematically design case-crossover analyses of large electronic medical records databases., Material and Methods: We developed IT-CARES, an analytical tool implementing case-crossover design, to explore the association between exposures and outcomes. The exposures and outcomes are defined by clinical epidemiologists via lists of codes entered via a user interface screen. We tested IT-CARES on data from the French national inpatient stay database, which documents diagnoses and medical procedures for 170 million inpatient stays between 2007 and 2013. We compared the results of our analysis with reference data from the literature on thromboembolic risk after delivery and bleeding risk after total hip replacement., Results: IT-CARES provides a user interface with 3 columns: (i) the outcome criteria in the left-hand column, (ii) the exposure criteria in the right-hand column, and (iii) the estimated risk (odds ratios, presented in both graphical and tabular formats) in the middle column. The estimated odds ratios were consistent with the reference literature data., Discussion: IT-CARES may enhance patient safety by facilitating clinical epidemiological studies of adverse events following medical procedures. The tool's usability must be evaluated and improved in further research., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Prophylactic anticoagulation is recommended up to 35days after total hip replacement (THR). Although several observational studies have assessed the incidence of thrombotic events or bleeding events after THR, the corresponding measures of association have never been studied concomitantly. Here, we evaluated the duration of the elevated risks (relative to the baseline risk) of both venous thromboembolic events and bleeding events after THR for coxarthrosis among middle-aged patients. This was a population-based, cross-over cohort study of data extracted from the French national inpatient database between 2007 and 2013. We included middle-aged patients (aged 45 to 69) having undergone THR for coxarthrosis. We compared the numbers of pulmonary embolisms (PEs) (respectively upper gastrointestinal bleedings (UGIBs)) following the THR with the numbers occurring during three unexposed periods one year later. This enabled us to estimate the odds ratio (OR) [95% confidence interval (CI)] for each of six successive 35-day intervals. The study included 108,099 patients. The ORs for PE were respectively 12.4 (95% CI, 8.6-17.8) (absolute risk difference rate per 100,000 (ARD/100,000)=130) and 5.0 (95% CI, 3.4-7.4) (ARD/100,000=52) for the first two 35-day intervals, and the risk was close to 1 thereafter. The risk of UGIB fell quickly, with an OR of 6.5 (95% CI, 4.6-9.1) (ARD/100,000=83) and 0.8 (95% CI, 0.4-1.6) for the first two 35-day intervals, respectively. The majority of UGIBs occurred during the inpatient stay for THR. Among middle-aged patients, the risk of a PE remains elevated beyond 35days after THR for coxarthrosis, whereas the risk of a UGIB remains elevated for the first 35days only., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Although a population's senescence rate is classically measured as the increase in mortality rate with age on a logarithmic scale, it may be more accurately measured as the increase on a linear scale. Patients on dialysis, who suffer from accelerated senescence, exhibit a smaller increase in their mortality rate on a logarithmic scale, but a larger increase on a linear scale than patients with a functioning kidney transplant. However, this comparison may be biased by population heterogeneity., Methods: Follow-up data on 323,308 patients on dialysis and 91,679 patients with a functioning kidney transplant were derived from the ERA-EDTA Registry. We measured the increases in their mortality rates using Gompertz frailty models that allow individual variation in this increase., Results: According to these models, the senescence rate measured as the increase in mortality rate on a logarithmic scale was smaller in patients on dialysis, while the senescence rate measured as the increase on a linear scale was larger in patients on dialysis than patients with a functioning kidney transplant., Conclusions: Also when accounting for population heterogeneity, a population's senescence rate is more accurately measured as the increase in mortality rate on a linear scale than a logarithmic scale., (Copyright © 2016 Elsevier Inc. All rights reserved.)

A significant number of elderly patients die during their first 3 months of dialysis. Because dialysis can impair the quality of both life and death, a personalized care plan based on both early prognosis and patient choices is required. We developed a prognostic screening tool to identify older patients in need of specific care based on a multidisciplinary approach. Our study included 24,348 patients aged 75 years and older from the French national renal epidemiology and information network (REIN) registry who began dialysis between 1 January 2005 and 30 September 2012. Our primary outcome was overall mortality during the first 3 months of renal replacement therapy. Multivariate logistic regression was used to construct a scoring system in a random half of the cohort (training set). This score, which included age, gender, specific comorbidities, albumin levels, and mobility, was then applied to the other half (validation set). In all, 2548 patients died during the first 3 months after dialysis initiation, 22% after dialysis withdrawal. Three risk groups were identified: low risk (score under 12 points, 3-month expected mortality under 20%), intermediate risk (score from 12 to 16, mortality between 20 and 40%, 9.5% of patients) and high risk (score 17 or more, mortality over 40%, 2.5% of patients). We developed a decision-making process that classifies patients according to their risk of early death in view of their potentially imminent need for supportive care or treatment.

Acrylamide (AAM) has been recently discovered in food as a Maillard reaction product. AAM and glycidamide (GA), its metabolite, have been described as probably carcinogenic to humans. It is widely established that senescence and carcinogenicity are closely related. In vitro, endothelial aging is characterized by replicative senescence in which primary cells in culture lose their ability to divide. Our objective was to assess the effects of AAM and GA on human endothelial cell senescence. Human umbilical vein endothelial cells (HUVECs) cultured in vitro were used as model. HUVECs were cultured over 3 months with AAM or GA (1, 10 or 100 μM) until growth arrest. To analyze senescence, β-galactosidase activity and telomere length of HUVECs were measured by cytometry and semi-quantitative PCR, respectively. At all tested concentrations, AAM or GA reduced cell population doubling compared to the control condition (p < 0.001). β-galactosidase activity in endothelial cells was increased when exposed to AAM (≥10 μM) or GA (≥1 μM) (p < 0.05). AAM (≥10 μM) or GA (100 μM) accelerated telomere shortening in HUVECs (p < 0.05). In conclusion, in vitro chronic exposure to AAM or GA at low concentrations induces accelerated senescence. This result suggests that an exposure to AAM might contribute to endothelial aging., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Under-prescription of anticoagulants in the elderly with atrial fibrillation (AF) has been described in several studies, showing that only 15 to 44% of them receive anticoagulants. However, the European Society of Cardiology recommendations state that anticoagulants should be systematically prescribed. In case of refusal of the treatment by the patient, a platelet aggregation inhibitor should be prescribed in monotherapy or bitherapy according to the HAS-BLED bleeding risk score. In all the cases the patient should receive an antithrombotic treatment. In this work we observe the adequacy of prescription practices to the recommendations for AF in the elderly by data reuse on a monocentric observational retrospective cohort. Data of a 222 beds French community hospital were extracted for the year 2013. The patients aged over 75 years and presenting AF were selected. The HAS-BLED score was calculated and the consistency of the prescriptions with the recommendations of the European Society of Cardiology was verified. Then the compliance rate to the recommendations was calculated. The rules detected 433 patients with AF and aged over 75 years. From those patients, 45% received an anticoagulant, 32.1% received platelet aggregation inhibitors and 22.9% did not receive any antithrombotic treatment. When a platelet aggregation inhibitor was prescribed the recommendation for bitherapy was not followed in 97% of the cases. The compliance rate to the recommendations was 47.8%. This work highlights a major problem of quality of the prescriptions in the hospital field and shows how data reuse can help describing this type of issues.

Prescriptions of PIMs and anticholinergic drugs lead to adverse events and hospitalizations in the elderly. The objective of this study was to determine the prevalence of PIMs and prescriptions with a high anticholinergic effect in a French region. All prescriptions dispensed at community pharmacies in patients aged 75 and older between January 1 and March 31, 2012 were extracted from French Health Insurance information System - Nord-Pas-de-Calais Region for patients affiliated to the Social Security. Prescription of PIMs was defined according to the Laroche list. The anticholinergic score for each prescription was calculated using the Anticholinergic Drug Scale (ADS). 65.6% (n=207,979) of people aged over 75 years, living in the Nord-Pas-de-Calais Region were included, of which 4.5% (n=9284) living in nursing homes. Patients received an average of 8.3 drugs over the 3-month study period. In 32.6% (n=67,863) of patients, at least one PMI was prescribed. According to the ADS, 10.0% (n=20,978) of patients in the general population and 24.0% (n=2231) of patients living in nursing homes was exposed to a prescription with a high or very high anticholinergic score (ADS≥3). Hydroxyzine prescribed in 51.4% (n=10,792) of them ranked first among drugs most often reported. In conclusion, PMIs and anticholinergic drugs were commonly prescribed in elderly living in the Nord-Pas-de-Calais Region. Improving the quality of prescriptions in the elderly appears necessary., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Medical free-text records enable to get rich information about the patients, but often need to be de-identified by removing the Protected Health Information (PHI), each time the identification of the patient is not mandatory. Pattern matching techniques require pre-defined dictionaries, and machine learning techniques require an extensive training set. Methods exist in French, but either bring weak results or are not freely available. The objective is to define and evaluate FASDIM, a Fast And Simple De-Identification Method for French medical free-text records., Methods: FASDIM consists in removing all the words that are not present in the authorized word list, and in removing all the numbers except those that match a list of protection patterns. The corresponding lists are incremented in the course of the iterations of the method. For the evaluation, the workload is estimated in the course of records de-identification. The efficiency of the de-identification is assessed by independent medical experts on 508 discharge letters that are randomly selected and de-identified by FASDIM. Finally, the letters are encoded after and before de-identification according to 3 terminologies (ATC, ICD10, CCAM) and the codes are compared., Results: The construction of the list of authorized words is progressive: 12h for the first 7000 letters, 16 additional hours for 20,000 additional letters. The Recall (proportion of removed Protected Health Information, PHI) is 98.1%, the Precision (proportion of PHI within the removed token) is 79.6% and the F-measure (harmonic mean) is 87.9%. In average 30.6 terminology codes are encoded per letter, and 99.02% of those codes are preserved despite the de-identification., Conclusion: FASDIM gets good results in French and is freely available. It is easy to implement and does not require any predefined dictionary., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)