A Dynamic Query-Rewriting Mechanism for Role-Based Access Control in Databases

Although Role-Based Access Control (RBAC) is a common security model currently, it has not been systematically applied in databases. In this paper, we propose a framework that enforces RBAC based on dynamic query rewriting. This framework grants privileges to data based on an intersection of roles, database structures, content, and privileges. All of this is implemented at the database level, which also offers a centralized location for administering security policies. We have implemented the framework within a healthcare setting

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Combining Natural Language Processing and Statistical Text Mining: A Study of Specialized Versus Common Languages

This dissertation focuses on developing and evaluating hybrid approaches for analyzing free-form text in the medical domain. This research draws on natural language processing (NLP) techniques that are used to parse and extract concepts based on a controlled vocabulary. Once important concepts are extracted, additional machine learning algorithms, such as association rule mining and decision tree induction, are used to discover classification rules for specific targets. This multi-stage pipeline approach is contrasted with traditional statistical text mining (STM) methods based on term counts and term-by-document frequencies. The aim is to create effective text analytic processes by adapting and combining individual methods. The methods are evaluated on an extensive set of real clinical notes annotated by experts to provide benchmark results. There are two main research question for this dissertation. First, can information (specialized language) be extracted from clinical progress notes that will represent the notes without loss of predictive information? Secondly, can classifiers be built for clinical progress notes that are represented by specialized language? Three experiments were conducted to answer these questions by investigating some specific challenges with regard to extracting information from the unstructured clinical notes and classifying documents that are so important in the medical domain. The first experiment addresses the first research question by focusing on whether relevant patterns within clinical notes reside more in the highly technical medically-relevant terminology or in the passages expressed by common language. The results from this experiment informed the subsequent experiments. It also shows that predictive patterns are preserved by preprocessing text documents with a grammatical NLP system that separates specialized language from common language and it is an acceptable method of data reduction for the purpose of STM. Experiments two and three address the second research question. Experiment two focuses on applying rule-mining techniques to the output of the information extraction effort from experiment one, with the ultimate goal of creating rule-based classifiers. There are several contributions of this experiment. First, it uses a novel approach to create classification rules from specialized language and to build a classifier. The data is split by classification and then rules are generated. Secondly, several toolkits were assembled to create the automated process by which the rules were created. Third, this automated process created interpretable rules and finally, the resulting model provided good accuracy. The resulting performance was slightly lower than from the classifier from experiment one but had the benefit of having interpretable rules. Experiment three focuses on using decision tree induction (DTI) for a rule discovery approach to classification, which also addresses research question three. DTI is another rule centric method for creating a classifier. The contributions of this experiment are that DTI can be used to create an accurate and interpretable classifier using specialized language. Additionally, the resulting rule sets are simple and easily interpretable, as well as created using a highly automated process

Finding Falls in Ambulatory Care Clinical Documents Using Statistical Text Mining

Objective: To determine how well statistical text mining (STM) models can identify falls within clinical text associated with an ambulatory encounter. Materials and Methods: 2241 patients were selected with a fall-related ICD-9-CM E-code or matched injury diagnosis code while being treated as an outpatient at one of four sites within the Veterans Health Administration. All clinical documents within a 48-h window of the recorded E-code or injury diagnosis code for each patient were obtained (n=26 010; 611 distinct document titles) and annotated for falls. Logistic regression, support vector machine, and cost-sensitive support vector machine (SVM-cost) models were trained on a stratified sample of 70% of documents from one location (dataset Atrain) and then applied to the remaining unseen documents (datasets Atest-D). Results: All three STM models obtained area under the receiver operating characteristic curve (AUC) scores above 0.950 on the four test datasets (Atest-D). The SVM-cost model obtained the highest AUC scores, ranging from 0.953 to 0.978. The SVM-cost model also achieved F-measure values ranging from 0.745 to 0.853, sensitivity from 0.890 to 0.931, and specificity from 0.877 to 0.944. Discussion: The STM models performed well across a large heterogeneous collection of document titles. In addition, the models also generalized across other sites, including a traditionally bilingual site that had distinctly different grammatical patterns. Conclusions: The results of this study suggest STM-based models have the potential to improve surveillance of falls. Furthermore, the encouraging evidence shown here that STM is a robust technique for mining clinical documents bodes well for other surveillance-related topics

Improving Identification of Fall-Related Injuries in Ambulatory Care Using Statistical Text Mining

Objectives. We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities. Methods. We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review. Results. STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical. Conclusions. STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system