Euthymia in Diabetes: Clinical Evidence and Practice-Based Opinion from an International Expert Group

AIM

To develop an evidence-based expert group opinion on various types of euthymia associated with diabetes mellitus (DM) and its management.

BACKGROUND

Diabetes mellitus is a metabolic syndrome characterized by diverse biomedical and psychosocial features. Emotional health disturbances may lead to psychological and psychiatric dysfunction and may negatively influence glycemic control. Patients with DM may experience diabetes distress (DD) associated with burden of self-care, interpersonal issues, and emotional worries regarding the ability to cope with the illness. Euthymia or a state of positive mental health and psychological well-being should be considered a key outcome of diabetes care. Therefore, to achieve optimal outcomes, the consideration and measurement of psychological and psychiatric aspects along with glycemic levels are very important. A group of multidisciplinary clinical experts came together in an international meeting held in India to develop a workable concept for euthymia in diabetes care. A multidisciplinary approach was suggested to enhance the clinical outcomes and facilitate patient-centered care. During the meeting emphasis was given to the concept of a euthymia model in diabetes care. This model focuses on enhancement of self-care skills in diabetic patients and preventative health awareness among diabetes care providers. Euthymia also encompasses patient-provider communication to aid enhancement of coping skills.

RESULTS

After due discussions and extensive deliberations, the expert group provided several recommendations on implementing the concept of euthymia in DM care.

CONCLUSIONS

Introduction of the concept of euthymia in routine clinical practice is important to improve the quality of life and coping skills in patients with DM. A timely clinical assessment of psychological and psychiatric aspects along with patient-reported outcomes of diabetes contributes to overall health and well-being of affected individuals.

FUNDING

Sanofi India.

Hierarchical patient-centric caregiver network method for clinical outcomes study

In clinical outcome studies, analysis has traditionally been performed using patient-level factors, with minor attention given to provider-level features. However, the nature of care coordination and collaboration between caregivers (providers) may also be important in determining patient outcomes. Using data from patients admitted to intensive care units at a large tertiary care hospital, we modeled the caregivers that provided medical service to a specific patient as patient-centric subnetwork embedded within larger caregiver networks of the institute. The caregiver networks were composed of caregivers who treated either a cohort of patients with particular disease or any patient regardless of disease. Our model can generate patient-specific caregiver network features at multiple levels, and we demonstrate that these multilevel network features, in addition to patient-level features, are significant predictors of length of hospital stay and in-hospital mortality.

Database on spermatozoa transcriptogram of catagorised Frieswal crossbred (Holstein Friesian X Sahiwal) bulls

Bull spermatozoa contain different functional genes and many of them plays important roles in different stages of spermatogenesis, spermatozoa kinetics, fertilization as well as embryonic development. RNA deep sequencing is one of the preferred tools for absolute quantification of messenger RNA. The intention of the current study was to investigate the abundance of spermatozoal transcripts in categorized Frieswal (Holstein-Friesian X Sahiwal) crossbred bull semen through RNA deep sequencing. A total 1546561 and 1019308 numbers of reads were identified among good and poor quality bull spermatozoa based on their conception rate. Post mapping with Bos taurus reference genome identified 1,321,236 and 842,022 number of transcripts among good and poor quality RNA libraries, respectively. However, a total number of 3510 and 6759 functional transcripts were identified among good and poor quality bull spermatozoa, respectively. Most of the identified transcripts were related to spermatozoa functions, embryonic development and other functional aspects of fertilization. Wet laboratory validation of the top five selected transcripts (AKAP4, PRM1, ATP2B4, TRIM71 and SLC9B2) illustrated the significant (p < 0.01) level of expression in the good quality crossbred bull semen than the poor quality counterparts. The present study with comprehensive profiling of spermatozoal transcripts provides a useful non-invasive tool to understand the causes of as well as an effective way to predict male infertility in crossbred bulls.

Adipose tissue polyunsaturated fatty acids and metabolic syndrome among adult parents and their children

BACKGROUND AND AIMS

Polyunsaturated fatty acids (PUFA) may play a role in the etiology of the metabolic syndrome (MetS). The aim of the study was to examine the associations of adipose tissue PUFA biomarkers with MetS among parents and children in Mesoamerica.

METHOD AND RESULTS

We conducted a cross-sectional study among 468 parents and 201 children aged 7-12 y from the capital cities of Guatemala, El Salvador, the Dominican Republic, Honduras, Nicaragua, Panama, Costa Rica, and Belize, and Tuxtla Gutiérrez in Mexico. We measured PUFA biomarkers in gluteal adipose tissue by gas chromatography. In adults, MetS was defined according to the National Cholesterol Education Program's Adult Treatment Panel III definition. In children, we created an age- and sex-standardized metabolic risk score using abdominal circumference, the homeostasis model of insulin resistance, blood pressure, serum HDL cholesterol, and triglycerides. We estimated prevalence ratios of MetS and mean differences in metabolic score across quartiles of PUFA using multivariable-adjusted Poisson and linear regression models, respectively. Among adults, MetS was associated with low alpha-linolenic acid (ALA), high eicosapentaenoic acid (EPA), and low gamma-linolenic acid (GLA). It was linearly, positively associated with dihomo-gamma-linolenic acid (DGLA) and estimated Δ6-desaturase (D6D) activity. Among children, the metabolic score was positively associated with docosapentaenoic acid (DPA), DGLA, and D6D activity.

CONCLUSIONS

Among Mesoamerican adults, MetS prevalence is inversely associated with adipose tissue ALA and GLA, and positively associated with EPA, DGLA, and the D6D index. Among children, metabolic risk score is positively associated with DPA, DGLA, and the D6D index.

Prescription fill rates for acute and chronic medications in claims-EMR linked data

Nonadherence to prescribed medications poses a significant public health problem. Prescription data in electronic medical records (EMRs) linked with pharmacy claims data provides an opportunity to examine the prescription fill rates and factors associated with it.Using a claims-EMR linked data, patients who had a prescription for either an antibiotic, antihypertensive, or antidiabetic in EMR were identified (index prescription). Prescription fill was defined as a pharmacy claim found within the 90 days following the EMR prescription. For each medication group, patient characteristics and fill rates were examined using descriptive statistics. Multivariate logistic regression was used to evaluate the association between fill rates and factors such as age, race, brand vs generic, and prior treatment during 365 days before the index date.Among 77,996 patients with index antibiotic prescription, 78,462 with index antihypertensive prescription, and 24,013 with index antidiabetic prescription, the prescription fill rate was 73%, 74%, and 76%, respectively. Overall, African American race was negatively associated with fill rates (odds ratio [OR] 0.8 for all 3 groups). Prior treatment history was positively associated with antihypertensives (OR 5.6, 95% confidence interval [CI] 5.4-5.7) or antidiabetics (OR 4.1, CI 3.8-4.4) but negatively with antibiotics (OR 0.6, CI 0.6-0.6). Older age was an additional factor that was negatively associated with first time fill rate among patients without prior treatment.Significant proportions of patients, especially patients with no prior treatment history, did not fill prescriptions for antibiotics, antihypertensives, or antidiabetics. The association between patient factors and medication fill rates varied across different medication groups.

Experimental and Numerical Assessment of Temperature Field and Analysis of Microstructure and Mechanical Properties of Low Power Laser Annealed Welded Joints

In this present work, laser welding experiments were carried out on 1 mm thin Ti6Al4V sheets using a low power Nd-YAG laser machine without using any filler wire and without edge preparation of welding specimens. The influence of different major process control parameters such as welding speed and power on the yield parameters like temperature field, weld bead geometry, microstructure, and mechanical properties are critically investigated. Experimental results are compared in detail with the simulated results obtained using a commercial 3D finite element model. In the simulation model, temperature-dependent thermal and mechanical properties of plates were considered. The temperature readings were recorded with the aid of K type thermocouples. Forced convection has been assumed near weld zone region because of the movement of the shielding gas. Appreciable agreement is found between the experimental and the simulated temperature fields in most of the cases with few exceptions. These deviations on few occasions may be due to the presence of uncertainties inherently present in the experimental domain and uncertainties in the subsequent temperature sensing techniques by the thermocouples. In addition, annealing has been done at 950 °C, 980 °C, and 1010 °C for one selected parameter (192 W, 6 mm/s). The tensile strength of the samples annealed at 980 °C has been found to be 1048 MPa and it is 3% to 4% higher than that of the usual welded samples.

Sociotechnical Challenges of Developing an Interoperable Personal Health Record: Lessons Learned

OBJECTIVES: To analyze sociotechnical issues involved in the process of developing an interoperable commercial Personal Health Record (PHR) in a hospital setting, and to create guidelines for future PHR implementations. METHODS: This qualitative study utilized observational research and semi-structured interviews with 8 members of the hospital team, as gathered over a 28 week period of developing and adapting a vendor-based PHR at Lucile Packard Children's Hospital at Stanford University. A grounded theory approach was utilized to code and analyze over 100 pages of typewritten field notes and interview transcripts. This grounded analysis allowed themes to surface during the data collection process which were subsequently explored in greater detail in the observations and interviews. RESULTS: Four major themes emerged: (1) Multidisciplinary teamwork helped team members identify crucial features of the PHR; (2) Divergent goals for the PHR existed even within the hospital team; (3) Differing organizational conceptions of the end-user between the hospital and software company differentially shaped expectations for the final product; (4) Difficulties with coordination and accountability between the hospital and software company caused major delays and expenses and strained the relationship between hospital and software vendor. CONCLUSIONS: Though commercial interoperable PHRs have great potential to improve healthcare, the process of designing and developing such systems is an inherently sociotechnical process with many complex issues and barriers. This paper offers recommendations based on the lessons learned to guide future development of such PHRs.

Association of Physicians of India: Position Statement on Role of Chirally Pure Molecules in Clinical Practice

Chirally pure molecules or enantiomers are non-superimposable mirror images of each other with a chiral center (such as carbon, sulphur, nitrogen or phosphorous atom). An equimolar mixture of enantiomers forms a racemate. Chirally pure molecules (single enantiomers) are important in the field of drug discovery as the drug targets such as enzymes and receptors are enantioselective in nature. Clinical studies have demonstrated that chirally pure drugs exhibit different pharmacokinetic and metabolic profiles, reduced adverse events, improved safety profiles and similar therapeutic activity at lowered drug dosage as compared with the racemate in many therapeutic areas. However, since there is a low level of awareness on the advantages of chirally pure molecules among clinicians, pharmacists and patients in India, the Association of Physicians of India (API) developed this position statement to increase awareness on the concept of chirality and the associated advantages of using chirally pure drugs in certain therapeutic areas to maximize patient outcomes. This includes the clinical evidence associated with single enantiomers such as S-metoprolol, S-amlodipine, esomeprazole, escitalopram, levobupivacaine, cisatracurium, S-etodolac, dexketoprofen, levofloxacin in terms of efficacy and safety as compared with their racemates. In addition, the API also provides some tactical recommendations for clinicians, pharmacists, patients, regulatory body and pharmaceutical companies to increase awareness on chirally pure drugs and puts forth the need for expedited availability of chirally pure drugs in the Indian market.

Diabetes and Anemia: International Diabetes Federation (IDF) - Southeast Asian Region (SEAR) position statement

Anemia is often associated with diabetes mellitus and is known to intensify the risk of developing diabetes-related microvascular and macrovascular complications. There is paucity in understanding of co-existence of these conditions, especially in Southeast Asian countries. Iron and/or erythropoietin deficiencies are the major causes of anemia in diabetes, and diabetic kidney disease plays a key role. Patients with diabetes need to be screened for anemia along with other risk factors and anemia should be corrected appropriately to improve overall clinical outcomes. This position statement aims to provide a comprehensive overview and an algorithm for appropriate management of anemia in patients with diabetes.

Indian College of Physicians Position Statement: Addictive Disorders Among Persons with Diabetes Mellitus

OBJECTIVES

Migraine, a common primary headache disorder which can be severely disabling, associated with poor health-related quality of life (HRQoL) amongst affected patients. The present study was performed to provide adequate clinical data on migraine and the management practices in India.

MATERIAL AND METHODS

A cross-sectional study was designed to assess disease burden, HRQoL, symptom profile, management trends and comorbidities associated with migraine patients across ten centres in India. This study assessed HRQoL using Migraine Specific Quality of life (MSQ) and Migraine Disability Assessment Scores (MIDAS) questionnaire. Categorical variables were summarized as frequency, and percentage and continuous variables as mean and standard deviation respectively.

RESULTS

A total of 705 patients were enrolled with a mean age of 35.2 years. Hypertension (7.0%) was the highest co-morbid illness associated with migraine. A higher MSQ score was observed in females as compared to males (39.3±12.4 and 37.4±11.6) while MIDAS showed a comparable score (27.7±47.6 and 27.2±35.4). Majority of migraine patients were unemployed (61.6%) and in profession, females had poor HRQoL than males by MIDAS and MSQ. Majority of patients had pulsating, bilateral attacks for the duration of 4h to 72 h. Paracetamol (47.1%) and propranolol (50.9%) was most commonly prescribed drugs for acute attack and prophylaxis, respectively.

CONCLUSION

The quality of life was superior in males as compared to females amongst migraine patients in India. Hypertension was the commonest comorbidity associated with migraine.

KEY MESSAGES

Migraine is associated with substantial disability with higher prevalence in females and older people (age >40 years). NSAIDs and propanol was widely prescribed drug in acute attacks and prophylaxis of migraine respectively. Cardiovascular diseases, diabetes mellitus and anxiety were common comorbidities associated with migraine.

Publish and flourish: Take the road less travelled!

Scientific research and publications are essential for advancement of medical knowledge. The perceived need for 'publications' in medical journals, has increased substantially in view of the recently mandated requirement of original research publications in indexed journals to ensure career progression in academic institutions. There has been an unprecedented rise in the number of standalone journals and publishers, ready to process manuscripts on priority with almost guaranteed publication, at a cost. Many of these publishers have questionable credibility and could be regarded as 'predatory'. It is imperative for a concerted and broad based initiative to foster awareness creation among students at the post-graduate level and for faculty of medical colleges and research institutions. We need to adopt stringent measures to curtail this scourge of predatory publishing. It is advisable for researchers to take the road less travelled, and publish in 'reputed' and 'accepted' journals to flourish. This article aims to bring focus on to the present situation in the scientific publication arena in the Indian context, highlight emerging threats and suggest possible remedies.

Association of Angiotensin-Converting Enzyme Gene Polymorphisms and Nephropathy in Diabetic Patients at a Tertiary Care Centre in South India

Background:

Genetic polymorphisms of the angiotensin-renin pathway have been thought to influence the development of diabetic nephropathy. However, there are conflicting results regarding this association in previous studies on populations with varying ethnicity.

Aims:

Primary aim was to compare the frequency of distribution of angiotensin-converting enzyme (ACE) gene (insertion/deletion [I/D]) polymorphism in Tamilian Indian type 2 diabetic individuals with and without microalbuminuria. Secondary objective was to compare the frequency of distribution of the 3 genotypes in diabetic patients with urinary albumin/creatinine ratio (ACR) < 30 mg/dL, urinary ACR = 30 to 300 mg/dL, and urinary ACR > 300 mg/dL.

Methods:

A total of 179 consecutive diabetic individuals between 40 and 70 years, from Puducherry and Tamilnadu of Dravidian descent participated in the study conducted from 2012 to 2014. Inclusion criteria were as follows: age ≥ 40 years and duration of type 2 diabetes mellitus for ≥5 years. Patients were divided into 2 groups based on ACR values. Group 1 consisted of 50 individuals with urinary ACR < 30 mg/g of creatinine, and group 2 consisted of 129 individuals with urinary ACR > 30 mg/g. Angiotensin I–converting enzyme (ACE) gene polymorphism was determined by allele-specific polymerase chain reaction method using a primer pair flanking the polymorphic region of its intron 16. Furthermore, group 2 patients were subdivided into those with urinary ACR = 30 to 300 mg/g of creatinine and those with urinary ACR > 300 mg/g of creatinine, and distribution of ACE gene polymorphism was compared in the three groups.

Statistics:

Statistical analysis was done using SPSS version 17.0. Independent Student t test was used to compare mean values between the 2 groups. Odds ratio was calculated for testing association between ACE gene (I/D) polymorphism and presence of microalbuminuria. P < .05 was considered significant. Comparison of ACE genotypes among 3 groups of patients (ACR < 30 mg/g, ACR = 30-300 mg/g, and ACR > 300 mg/g) was done using 1-way analysis of variance with Bonferroni multiple comparison test as post hoc analysis.

Conclusions:

Heterozygous I/D genotype was more frequent in the study population (45.8%) than the other genotypes. There was no difference in the genotype distribution in patients with varying levels of albuminuria.

Textural pattern classification for oral squamous cell carcinoma

Despite being an area of cancer with highest worldwide incidence, oral cancer yet remains to be widely researched. Studies on computer-aided analysis of pathological slides of oral cancer contribute a lot to the diagnosis and treatment of the disease. Some researches in this direction have been carried out on oral submucous fibrosis. In this work an approach for analysing abnormality based on textural features present in squamous cell carcinoma histological slides have been considered. Histogram and grey-level co-occurrence matrix approaches for extraction of textural features from biopsy images with normal and malignant cells are used here. Further, we have used linear support vector machine classifier for automated diagnosis of the oral cancer, which gives 100% accuracy.

Application of a Loop-Mediated Isothermal Amplification Assay for Rapid Detection of Cow Components Adulterated in Buffalo Milk/Meat

Loop-mediated isothermal amplification (LAMP) is a diagnostic method for amplification of DNA with rapid and minimal equipment requirement. In the present study, we applied the LAMP assay for rapid detection of cow components adulteration in buffalo milk/meat samples. The test can be completed within around 1 h 40 min starting from DNA extraction and can be performed in water bath without requirement of thermocycler. The cow DNA in buffalo samples were identified in the developed LAMP assay by either visualizing with SYBR Green I/HNB dyes or observing the typical ladder pattern on gel electrophoresis. The test can detect up to 5 % level of cow milk/meat mixed in buffalo counterparts. Due to the simplicity and specificity, the developed LAMP test can be easily adapted in any laboratory for rapid detection of cow species identification in livestock by products.

Indian College of Physicians (ICP) Position Statement on Pharmacovigilance

Pharmacovigilance is the art and science of detection, understanding and prevention of adverse drug reactions and not merely a critical analysis of prescriptions and errors. This field starts with reporting by clinicians of a suspected adverse drug reaction (ADR) to the pharmacologist followed by joint causality analysis and ends at the application of new information by a clinician for benefit of patients. There are a number of ways, which can be utilised for reporting adverse effects using pen and paper format to software applications for smart phones. Varied types of activities spreading from systematic reviews to the mechanistic evaluation of ADR can be performed under the umbrella of pharmacovigilance. It is of utmost importance for clinicians to understand how to identify, communicate and understand adverse effects of drugs with an aim to prevent harm to patients.

Differences in Antipsychotic-Related Adverse Events in Adult, Pediatric, and Geriatric Populations

In recent years, antipsychotic medications have increasingly been used in pediatric and geriatric populations, despite the fact that many of these drugs were approved based on clinical trials in adult patients only. Preliminary studies have shown that the “off-label” use of these drugs in pediatric and geriatric populations may result in adverse events not found in adults. In this study, we utilized the large-scale U.S. Food and Drug Administration (FDA) Adverse Events Reporting System (AERS) database to look at differences in adverse events from antipsychotics among adult, pediatric, and geriatric populations. We performed a systematic analysis of the FDA AERS database using MySQL by standardizing the database using structured terminologies and ontologies. We compared adverse event profiles of atypical versus typical antipsychotic medications among adult (18-65), pediatric (age < 18), and geriatric (> 65) populations. We found statistically significant differences between the number of adverse events in the pediatric versus adult populations with aripiprazole, clozapine, fluphenazine, haloperidol, olanzapine, quetiapine, risperidone, and thiothixene, and between the geriatric versus adult populations with aripiprazole, chlorpromazine, clozapine, fluphenazine, haloperidol, paliperidone, promazine, risperidone, thiothixene, and ziprasidone (p < 0.05, with adjustment for multiple comparisons). Furthermore, the particular types of adverse events reported also varied significantly between each population for aripiprazole, clozapine, haloperidol, olanzapine, quetiapine, risperidone, and ziprasidone (Chi-square, p < 10^-6). Diabetes was the most commonly reported side effect in the adult population, compared to behavioral problems in the pediatric population and neurologic symptoms in the geriatric population. We also found discrepancies between the frequencies of reports in AERS and in the literature. Our analysis of the FDA AERS database shows that there are significant differences in both the numbers and types of adverse events among these age groups and between atypical and typical antipsychotics. It is important for clinicians to be mindful of these differences when prescribing antipsychotics, especially when prescribing medications off-label.

Mesenchymal stromal cells for cartilage repair in osteoarthritis

Treatment for articular cartilage damage is quite challenging as it shows limited repair and regeneration following injury. Non-operative and classical surgical techniques are inefficient in restoring normal anatomy and function of cartilage in osteoarthritis (OA). Thus, investigating new and effective strategies for OA are necessary to establish feasible therapeutic solutions. The emergence of the new discipline of regenerative medicine, having cell-based therapy as its primary focus, may enable us to achieve repair and restore the damaged articular cartilage. This review describes progress and development of employing mesenchymal stromal cell (MSC)-based therapy as a promising alternative for OA treatment. The objective of this review is to first, discuss how in vitro MSC chondrogenic differentiation mimics in vivo embryonic cartilage development, secondly, to describe various chondrogenic differentiation strategies followed by pre-clinical and clinical studies demonstrating their feasibility and efficacy. However, several challenges need to be tackled before this research can be translated to the clinics. In particular, better understanding of the post-transplanted cell behaviour and learning to enhance their potency in the disease microenvironment is essential. Final objective is to underscore the importance of isolation, storage, cell shipment, route of administration, optimum dosage and control batch to batch variations to realise the full potential of MSCs in OA clinical trials.

'Peer review' for scientific manuscripts: Emerging issues, potential threats, and possible remedies

Reviewers play a vital role in ensuring quality control of scientific manuscripts published in any journal. The traditional double blind peer review, although a time-tested method, has come under increasing criticism in the face of emerging trends in the review process with the primary concern being the delays in completion of the review process. Other issues are the inability to detect errors/fraud, lack of transparency, lack of reliability, potential for bias, potential for unethical practices, lack of objectivity, inconsistencies amongst reviewers, lack of recognition and motivation of reviewers. Alternative options to classical peer review being propagated are: open review, immediate self-publication using preprint servers, nonselective review focusing primarily on the scientific content, and post-publication review. These alternative review processes, however, may suffer from the inability to validate quality control. In addition, anecdotal instances of peer review frauds are being reported more often than earlier. Suggested means to ensure quality of peer review process includes:(a) each journal to have its own database of reviewers, (b) verification of email IDs of reviewers provided by authors along with details of their institutions, (c) ensure credibility of reviewers before requesting for review, (d) check for plagiarism at the editorial level, (e) editors to distinguish between a good review from a possible biased/bad review, and (f) give recognition for reviewers once in a year. To conclude, quickness of review and publication should not dictate the scientific publication process at the cost of quality of contents.

Use of Gene Expression Profiling and Chemotherapy in Early-Stage Breast Cancer: A Study of Linked Electronic Medical Records, Cancer Registry Data, and Genomic Data Across Two Health Care Systems

PURPOSE

The 21-gene recurrence score (RS) identifies patients with breast cancer who derive little benefit from chemotherapy; it may reduce unwarranted variability in the use of chemotherapy. We tested whether the use of RS seems to guide chemotherapy receipt across different cancer care settings.

METHODS

We developed a retrospective cohort of patients with breast cancer by using electronic medical record data from Stanford University (hereafter University) and Palo Alto Medical Foundation (hereafter Community) linked with demographic and staging data from the California Cancer Registry and RS results from the testing laboratory (Genomic Health Inc., Redwood City, CA). Multivariable analysis was performed to identify predictors of RS and chemotherapy use.

RESULTS

In all, 10,125 patients with breast cancer were diagnosed in the University or Community systems from 2005 to 2011; 2,418 (23.9%) met RS guidelines criteria, of whom 15.6% received RS. RS was less often used for patients with involved lymph nodes, higher tumor grade, and age < 40 or ≥ 65 years. Among RS recipients, chemotherapy receipt was associated with a higher score (intermediate v low: odds ratio, 3.66; 95% CI, 1.94 to 6.91). A total of 293 patients (10.6%) received care in both health care systems (hereafter dual use); although receipt of RS was associated with dual use (v University: odds ratio, 1.73; 95% CI, 1.18 to 2.55), there was no difference in use of chemotherapy after RS by health care setting.

CONCLUSION

Although there was greater use of RS for patients who sought care in more than one health care setting, use of chemotherapy followed RS guidance in University and Community health care systems. These results suggest that precision medicine may help optimize cancer treatment across health care settings.

An Associative Memory Model for Integration of Fragmented Research Data and Identification of Treatment Correlations in Breast Cancer Care

A major challenge in advancing scientific discoveries using data-driven clinical research is the fragmentation of relevant data among multiple information systems. This fragmentation requires significant data-engineering work before correlations can be found among data attributes in multiple systems. In this paper, we focus on integrating information on breast cancer care, and present a novel computational approach to identify correlations between administered drugs captured in an electronic medical records and biological factors obtained from a tumor registry through rapid data aggregation and analysis. We use an associative memory (AM) model to encode all existing associations among the data attributes from both systems in a high-dimensional vector space. The AM model stores highly associated data items in neighboring memory locations to enable efficient querying operations. The results of applying AM to a set of integrated data on tumor markers and drug administrations discovered anomalies between clinical recommendations and derived associations.

Active and passive case detection strategies for the control of leishmaniasis in Bangladesh

SETTING

Two subdistricts in Bangladesh, Fulbaria and Trishal, which are hyperendemic for leishmaniasis.

OBJECTIVE

To determine 1) the numbers of patients diagnosed with visceral leishmaniasis (VL) and post-kala azar dermal leishmaniasis (PKDL) using an active case detection (ACD) strategy in Fulbaria and a passive case detection (PCD) strategy in Trishal, and 2) the time taken from symptoms to diagnosis in the ACD subdistrict.

DESIGN

A cross-sectional descriptive study of patients diagnosed from May 2010 to December 2011. The ACD strategy involved community education and outreach workers targeting households of index patients using symptom-based screening and rK-39 tests for suspected cases.

RESULTS

In the ACD subdistrict (Fulbaria) and PCD sub-district (Trishal), respectively 1088 and 756 residents were diagnosed with VL and 1145 and 37 with PKDL. In the ACD subdistrict, the median time to diagnosis for patients directly referred by outreach workers or self-referred was similar, at 60 days for VL and respectively 345 and 360 days for PKDL.

CONCLUSION

An ACD strategy at the subdistrict level resulted in an increased yield of VL and a much higher yield of PKDL. As PKDL acts as a reservoir for infection, a strategy of ACD and treatment can contribute to the regional elimination of leishmaniasis in the Indian sub-continent.

Place of sulfonylureas in the management of type 2 diabetes mellitus in South Asia: A consensus statement

Since their introduction in clinical practice in the 1950's, Sulfonylureas (SUs) have remained the main-stay of pharmacotherapy in the management of type 2 diabetes. Despite their well-established benefits, their place in therapy is inappropriately being overshadowed by newer therapies. Many of the clinical issues associated with the use of SUs are agent-specific, and do not pertain to the class as such. Modern SUs (glimepiride, gliclazide MR) are backed by a large body of evidence, experience, and most importantly, outcome data, which supports their role in managing patients with diabetes. Person-centred care, i.e., careful choice of SU, appropriate dosage, timing of administration, and adequate patient counseling, will ensure that deserving patients are not deprived of the advantages of this well-established class of anti-diabetic agents. Considering their efficacy, safety, pleiotropic benefits, and low cost of therapy, SUs should be considered as recommended therapy for the treatment of diabetes in South Asia. This initiative by SAFES aims to encourage rational, safe and smart prescription of SUs, and includes appropriate medication counseling.

Uphill Movement of Sessile Droplets by Electrostatic Actuation

The dynamics of uphill motion and the internal circulation of a sessile droplet by inducing asymmetric electrocapillarity were formulated and investigated numerically. We developed and analyzed a coupled electro-hydrodynamic model that includes conservative body and surface forces along with electrostatic effects. The interplay between gravity and electrostatic actuation is influenced by induction voltage, the inclination of the surface, and the droplet volume. Actuation voltage on the sessile drop causes an internal circulation which, upon increasing strength, overcomes the gravitational pull to climb uphill. As uphill droplet climbing is a spatiotemporal phenomenon, droplet volume plays a major role in accommodating the internal circulations and subsequent climb. Simultaneously, actuation due to electrostatic force behaves differently on different inclined surfaces, causing a roll down at higher inclination and an uphill climb at lower ones. A pattern map has been generated to identify favorable conditions for uphill movement based on the inclination, actuation voltage, and volume of the droplet.

Urinary Ascites - A Consequence of Intraoperative Injury

Patients with complications after surgery often pose enormous challenges to physicians. We report the case of a young lady developing fever, oliguria and intractable ascites refererred to us after undergoing abdominal surgery. She was diagnosed subsequently to have a urinoma with urinary ascites masquerading as a case of sepsis. Percutaneous nephrostomy followed by definitive repair and reimplantation of ureter later led to subsidence of the symptoms.

Chromosomal copy number alterations for associations of ductal carcinoma in situ with invasive breast cancer

INTRODUCTION

Screening mammography has contributed to a significant increase in the diagnosis of ductal carcinoma in situ (DCIS), raising concerns about overdiagnosis and overtreatment. Building on prior observations from lineage evolution analysis, we examined whether measuring genomic features of DCIS would predict association with invasive breast carcinoma (IBC). The long-term goal is to enhance standard clinicopathologic measures of low- versus high-risk DCIS and to enable risk-appropriate treatment.

METHODS

We studied three common chromosomal copy number alterations (CNA) in IBC and designed fluorescence in situ hybridization-based assay to measure copy number at these loci in DCIS samples. Clinicopathologic data were extracted from the electronic medical records of Stanford Cancer Institute and linked to demographic data from the population-based California Cancer Registry; results were integrated with data from tissue microarrays of specimens containing DCIS that did not develop IBC versus DCIS with concurrent IBC. Multivariable logistic regression analysis was performed to describe associations of CNAs with these two groups of DCIS.

RESULTS

We examined 271 patients with DCIS (120 that did not develop IBC and 151 with concurrent IBC) for the presence of 1q, 8q24 and 11q13 copy number gains. Compared to DCIS-only patients, patients with concurrent IBC had higher frequencies of CNAs in their DCIS samples. On multivariable analysis with conventional clinicopathologic features, the copy number gains were significantly associated with concurrent IBC. The state of two of the three copy number gains in DCIS was associated with a risk of IBC that was 9.07 times that of no copy number gains, and the presence of gains at all three genomic loci in DCIS was associated with a more than 17-fold risk (P = 0.0013).

CONCLUSIONS

CNAs have the potential to improve the identification of high-risk DCIS, defined by presence of concurrent IBC. Expanding and validating this approach in both additional cross-sectional and longitudinal cohorts may enable improved risk stratification and risk-appropriate treatment in DCIS.

Anticancer Effect of AntiMalarial Artemisinin Compounds

The anti-malarial drug artemisinin has shown anticancer activity in vitro and animal experiments, but experience in human cancer is scarce. However, the ability of artemisinins to kill cancer cells through a variety of molecular mechanisms has been explored. A PubMed search of about 127 papers on anti-cancer effects of antimalarials has revealed that this class of drug, including other antimalarials, have several biological characteristics that include anticancer properties. Experimental evidences suggest that artemisinin compounds may be a therapeutic alternative in highly aggressive cancers with rapid dissemination, without developing drug resistance. They also exhibit synergism with other anticancer drugs with no increased toxicity toward normal cells. It has been found that semisynthetic artemisinin derivatives have much higher antitumor activity than their monomeric counterparts via mechanisms like apoptosis, arrest of cell cycle at G₀/G₁, and oxidative stress. The exact mechanism of activation and molecular basis of these anticancer effects are not fully elucidated. Artemisinins seem to regulate key factors such as nuclear factor-kappa B, survivin, NOXA, hypoxia-inducible factor-1α, and BMI-1, involving multiple pathways that may affect drug response, drug interactions, drug resistance, and associated parameters upon normal cells. Newer synthetic artemisinins have been developed showing substantial antineoplastic activity, but there is still limited information regarding the mode of action of these synthetic compounds. In view of the emerging data, specific interactions with established chemotherapy need to be further investigated in different cancer cells and their phenotypes and validated further using different semisynthetic and synthetic artemisinin derivatives.

Human bioequivalence evaluation of two losartan potassium tablets under fasting conditions

The bioequivalence of two different tablet formulations containing losartan potassium 100 mg was determined in healthy volunteers after a single oral dose in a randomized crossover study. Test and reference products were administered to 60 volunteers with 240 ml water after overnight fasting. Plasma concentrations of losartan and its active carboxylic acid metabolite were monitored over a period of 36 h after drug administration by validated LC/MS/MS analytical method. The pharmacokinetic parameters C_max, AUC_0-t, AUC_0-∞, AUC_0-t/AUC_0-∞, t_max, K_el and t_½ were determined from plasma concentration time profile of both formulations for losartan and its active metabolite losartan carboxylic acid and were found to be in good agreement. The carboxylic acid metabolite was considered for profiling purpose only. The analysis of variance did not show any significant difference between the two formulations and 90% confidence intervals for the ratio of C_max (84.89-104.09%), AUC_0-t (95.84-102.84%) and AUC_0-∞ (96.43-103.25%) values for losartan between the test and reference products were within the 80-125% interval, satisfying the bioequivalence criteria of the US FDA guidelines. These results indicate that the test and the reference products of losartan potassium are bioequivalent and, thus, may be prescribed interchangeably.

Multicentric, Hyaline Vascular Variant of Castleman's Syndrome

Castleman's disease is a nonneoplastic adenopathy, also known as angiofollicular or giant lymphnode hyperplasia. Its multicentric form presents with wide spread lymphadenopathy and systemic symptoms. POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes) is observed in 11-30 % of the patients with Castleman's disease (Dispenzieri et al., Blood 101:2496-2506, 2003). Tuberculosis and lymphoma are the common diagnosis in patients with clinical features of weight loss, lymphadenopathy, hepatosplenomegaly and lymphocyte predominant ascites. We had a similar presentation in a young male, who was a diabetic, with clinical features suggestive of probable tuberculous infiltration of abdomen and adrenals causing addisonian features, lymphocyte predominant ascites, hepatosplenomegaly and generalized lymphadenopathy. However, a pathological diagnosis of hyaline vascular variant of Castleman's disease was obtained on lymphnode biopsy, which propelled us into doing a skeletal survey and bonemarrow biopsy. A final diagnosis of multicentric Castleman's disease with reactive plasmacytosis was achieved. Patient had osteosclerotic lesion in the right femur with evidence of polyneuropathy, organomegaly, endocrinopathies and skin hyperpigmentation. He has improved on chemotherapy with melphan and dexamethasone. Hyaline vascular variant of Castleman's disease rarely presents with systemic symptoms. Follow up is essential, as they can manifest with complications like POEMS and lymphoma.

Breast cancer treatment across health care systems: linking electronic medical records and state registry data to enable outcomes research

BACKGROUND

Understanding of cancer outcomes is limited by data fragmentation. In the current study, the authors analyzed the information yielded by integrating breast cancer data from 3 sources: electronic medical records (EMRs) from 2 health care systems and the state registry.

METHODS

Diagnostic test and treatment data were extracted from the EMRs of all patients with breast cancer treated between 2000 and 2010 in 2 independent California institutions: a community-based practice (Palo Alto Medical Foundation; "Community") and an academic medical center (Stanford University; "University"). The authors incorporated records from the population-based California Cancer Registry and then linked EMR-California Cancer Registry data sets of Community and University patients.

RESULTS

The authors initially identified 8210 University patients and 5770 Community patients; linked data sets revealed a 16% patient overlap, yielding 12,109 unique patients. The percentage of all Community patients, but not University patients, treated at both institutions increased with worsening cancer prognostic factors. Before linking the data sets, Community patients appeared to receive less intervention than University patients (mastectomy: 37.6% vs 43.2%; chemotherapy: 35% vs 41.7%; magnetic resonance imaging: 10% vs 29.3%; and genetic testing: 2.5% vs 9.2%). Linked Community and University data sets revealed that patients treated at both institutions received substantially more interventions (mastectomy: 55.8%; chemotherapy: 47.2%; magnetic resonance imaging: 38.9%; and genetic testing: 10.9% [P < .001 for each 3-way institutional comparison]).

CONCLUSIONS

Data linkage identified 16% of patients who were treated in 2 health care systems and who, despite comparable prognostic factors, received far more intensive treatment than others. By integrating complementary data from EMRs and population-based registries, a more comprehensive understanding of breast cancer care and factors that drive treatment use was obtained.

Note: Design principles of a linear array multi-channel effusive metal-vapor atom source

Atomic beams can easily be produced by allowing atoms to effuse through a channel. In an earlier investigation [A. Majumder et al., Vacuum 83, 989 (2009)], we had designed, fabricated, and characterized an effusive metal-vapor source using collinear-array of multi-channel. In this note, we describe the theoretical basis of designing the source. Atom density in atomic beam has been estimated using a set of analytical expressions for long-channel operated in transparent mode. Parametric studies on aspect ratio of channel, inter-channel separation, beam width, and vertical distance from the source are carried out. They are useful in providing physical picture and optimizing design parameters.

A semantic-based method for extracting concept definitions from scientific publications: evaluation in the autism phenotype domain

BACKGROUND

A variety of informatics approaches have been developed that use information retrieval, NLP and text-mining techniques to identify biomedical concepts and relations within scientific publications or their sentences. These approaches have not typically addressed the challenge of extracting more complex knowledge such as biomedical definitions. In our efforts to facilitate knowledge acquisition of rule-based definitions of autism phenotypes, we have developed a novel semantic-based text-mining approach that can automatically identify such definitions within text.

RESULTS

Using an existing knowledge base of 156 autism phenotype definitions and an annotated corpus of 26 source articles containing such definitions, we evaluated and compared the average rank of correctly identified rule definition or corresponding rule template using both our semantic-based approach and a standard term-based approach. We examined three separate scenarios: (1) the snippet of text contained a definition already in the knowledge base; (2) the snippet contained an alternative definition for a concept in the knowledge base; and (3) the snippet contained a definition not in the knowledge base. Our semantic-based approach had a higher average rank than the term-based approach for each of the three scenarios (scenario 1: 3.8 vs. 5.0; scenario 2: 2.8 vs. 4.9; and scenario 3: 4.5 vs. 6.2), with each comparison significant at the p-value of 0.05 using the Wilcoxon signed-rank test.

CONCLUSIONS

Our work shows that leveraging existing domain knowledge in the information extraction of biomedical definitions significantly improves the correct identification of such knowledge within sentences. Our method can thus help researchers rapidly acquire knowledge about biomedical definitions that are specified and evolving within an ever-growing corpus of scientific publications.

A new design of indirectly heated cathode based strip type electron gun

A new design of indirectly heated solid cathode based electron gun (200 kW, 45 kV, 270° bent strip type electron gun) has been presented. The design issue addressed is the uniformity of temperature on the solid cathode using (a) a multi-segmented filament with variable height as the primary heat source and (b) trapezoidal shaped single long filament as the primary heat source. The proposed design in this paper is based on computer simulation and validated by extensive experimentations. The design emphasis is on maintaining uniform temperature on the solid cathode. The designed multi-segment filament and the single long filament provide a temperature uniformity on the solid cathode of about 250 K and 110 K, respectively. The better temperature uniformity inspite of the thermal expansion, in case of a single long filament tightly clamped at two ends, has been possible due to shaping of the single filament with a number of constituent sections such that the thermal expansion of different sections forming the actual filament takes care of not only the mechanical stability but also does not affect the emitting surface of the filament. Experiments show that the modified design achieves a one to one correspondence of the solid cathode length and the electron beam length emitted from the solid cathode.

Cystic schwannoma of the pelvis

Schwannomas are benign tumours that arise from the Schwann cells of nerve fibres. They commonly occur in the head and neck, mediastinum and extremities. They are extremely rare in the pelvis. These are usually slow-growing tumours and are often detected incidentally. Preoperative diagnosis is extremely difficult as there are no definitive signs on imaging. Aspiration biopsy is often inconclusive or misleading. Surgical excision is both diagnostic and therapeutic. As these tumours are often large in size, open excision is most commonly performed. We describe a case of a large, cystic schwannoma of the pelvis causing bladder outlet obstruction and bilateral hydroureteronephrosis. Complete surgical excision was performed laparoscopically.

Why is premixed insulin the preferred insulin? Novel answers to a decade-old question

A wide range of sources have been used to create an equally wide range of types of insulin (rapid acting, fast acting, premixed, intermediate acting and long acting). While some of these insulins are no longer in clinical use, others are being used extensively across the world. Premixed insulin is the most frequently prescribed and used insulin in Asia; basal insulin is more extensively used in USA. As compared with basal insulin alone, premixed regimens tend to lower HbA1c to a larger degree while providing enhanced convenience. It is a challenge for diabetologists to assess the conflicting guidelines and decide which one to follow. This is especially true with regard to choosing appropriate insulin for initiation of therapy. Besides, ethnicity may play a key role in determining choice of insulin therapy among different populations. Here, the authors discuss the various factors, pharmacological as well as psychological, that have made premixed insulins the preferred insulin for type 2 diabetes in India and the many parts of Asia. The authors utilize well known theories of psychology, namely generalization, cognitive dissonance and concordance to provide a rational explanation for the preference for premixed insulin that Indian people with diabetes, and their physicians, have.