Assessing the readiness of digital data infrastructure for opioid use disorder research

BACKGROUND

Gaps in electronic health record (EHR) data collection and the paucity of standardized clinical data elements (CDEs) captured from electronic and digital data sources have impeded research efforts aimed at understanding the epidemiology and quality of care for opioid use disorder (OUD). We identified existing CDEs and evaluated their validity and usability, which is required prior to infrastructure implementation within EHRs.

METHODS

We conducted (a) a systematic literature review of publications in Medline, Embase and the Web of Science using a combination of at least one term related to OUD and EHR and (b) an environmental scan of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Opioid-related data elements identified within the environmental scan were compared with related data elements contained within nine common health data code systems and each element was graded for alignment with match results categorized as "exact", "partial", or "none."

RESULTS

The literature review identified 5186 articles for title search, of which 75 abstracts were included for review and 38 articles were selected for full-text review. Full-text articles yielded 237 CDEs, only 12 (5.06%) of which were opioid-specific. The environmental scan identified 379 potential data elements and value sets across 9 data systems and libraries, among which only 84 (22%) were opioid-specific. We found substantial variability in the types of clinical data elements with limited overlap and no single data system included CDEs across all major data element types such as substance use disorder, OUD, medication and mental health. Relative to common health data code systems, few data elements had an exact match (< 1%), while 61% had a partial match and 38% had no matches.

CONCLUSIONS

Despite the increasing ubiquity of EHR data standards and national attention placed on the opioid epidemic, we found substantial fragmentation in the design and construction of OUD related CDEs and little OUD specific CDEs in existing data dictionaries, systems and literature. Given the significant gaps in data collection and reporting, future work should leverage existing structured data elements to create standard workflow processes to improve OUD data capture in EHR systems.

National Assessment of Surprise Coverage Gaps Provided to Simulated Patients Seeking Emergency Care

This cross-sectional study evaluates surprise coverage gaps in health insurance by using secret shopper phone call methods to assess whether hospital billing staff in the US are able to answer a set of patient questions about insurance coverage.

Urban and Rural Emergency Department Performance on National Quality Metrics for Sepsis Care in the United States

PURPOSE

The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs.

METHODS

We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs.

FINDINGS

Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤  .001; 91% urban vs 84% rural; P ≤  .001, respectively).

CONCLUSIONS

Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.

State of the National Emergency Department Workforce: Who Provides Care Where?

STUDY OBJECTIVE

We describe the current US emergency medicine workforce in terms of clinician type and examine rural and urban emergency medicine workforce differences.

METHODS

Using the 2014 Medicare Public Use Files, we performed a cross-sectional study of all clinicians receiving reimbursement for evaluation and management (E/M) services (levels 1 to 5) to Medicare fee-for-service Part B beneficiaries in the emergency department. Providers were defined as emergency physicians, nonemergency physicians, or advanced practice providers, corresponding with the Medicare Public Use Files data set. The primary outcome was the number of clinicians providing greater than 10 E/M claims tabulated as a distinct encounter. Urbanicity data were obtained from the National Bureau of Economic Research.

RESULTS

Of 58,641 unique emergency medicine clinicians, 35,856 (61.1%) were classified as emergency physicians, 8,397 (14.3%) as nonemergency physicians, and 14,360 (24.5%) as advanced practice providers. Among nonemergency physicians categorized as emergency medicine clinicians, family practice and internal medicine predominated (41.7% and 19.9%, respectively). Among advanced practice providers, physician assistants (68.4%) and nurse practitioners (31.5%) predominated. A total of 58,565 emergency medicine clinicians were mapped to 2,291 US counties or equivalents. Urban counties had a higher proportion of emergency physicians (63.9%) compared with rural counties (44.8%); 27.1% of counties had no emergency medicine clinicians and 41.4% of counties had no emergency physicians reimbursed by Medicare fee-for-service Part B.

CONCLUSION

This work establishes a new baseline estimate of the emergency care workforce, encompassing nearly 60,000 emergency medicine clinicians, of whom fewer than 2 in 3 were emergency physicians. Notable differences exist in the type of clinician staffing of emergency care between urban and rural communities.

The Determinants of Productivity in Medical Testing: Intensity and Allocation of Care

A large body of research has investigated whether physicians overuse care. There is less evidence on whether, for a fixed level of spending, doctors allocate resources to patients with the highest expected returns. We assess both sources of inefficiency, exploiting variation in rates of negative imaging tests for pulmonary embolism. We document enormous across-doctor heterogeneity in testing conditional on patient population, which explains the negative relationship between physicians' testing rates and test yields. Furthermore, doctors do not target testing to the highest risk patients, reducing test yields by one-third. Our calibration suggests misallocation is more costly than overuse.

The Determinants of Productivity in Medical Testing: Intensity and Allocation of Care

A large body of research has investigated whether physicians overuse care. There is less evidence on whether, for a fixed level of spending, doctors allocate resources to patients with the highest expected returns. We assess both sources of inefficiency exploiting variation in rates of negative imaging tests for pulmonary embolism. We document enormous across-doctor heterogeneity in testing conditional on patient population, which explains the negative relationship between physicians' testing rates and test yields. Furthermore, doctors do not target testing to the highest risk patients, reducing test yields by one third. Our calibration suggests misallocation is more costly than overuse.

Seasonal abundance & role of predominant Japanese encephalitis vectors Culex tritaeniorhynchus & Cx. gelidus Theobald in Cuddalore district, Tamil Nadu

Background & objectives:

Japanese encephalitis (JE) is the leading cause of viral encephalitis in Asia. The first major JE outbreak occurred in 1978 and since 1981 several outbreaks had been reported in the Cuddalore district (erstwhile South Arcot), Tamil Nadu, India. Entomological monitoring was carried out during January 2010 - March 2013, to determine the seasonal abundance and transmission dynamics of the vectors of JE virus, with emphasis on the role of Culex tritaeniorhynchus and Cx. gelidus.

Methods:

Mosquito collections were carried out fortnightly during dusk hours in three villages viz. Soundara Solapuram, Pennadam, Erappavur of Cuddalore district. Mosquitoes were collected during dusk for a period of one hour in and around the cattle sheds using oral aspirator and torch light. The collected mosquitoes were later identified and pooled to detect JE virus (JEV) infection by enzyme linked immunosorbent assay (ELISA).

Results:

A total of 46,343 mosquitoes comprising of 25 species and six genera were collected. Species composition included viz, Cx. tritaeniorhynchus (46.26%), Cx. gelidus (43.12%) and other species (10.62%). A total of 17,678 specimens (403 pools) of Cx. gelidus and 14,358 specimens (309 pools) of Cx. tritaeniorhynchus were tested, of which 12 pools of Cx. gelidus and 14 pools of Cx. tritaeniorhynchus were positive for JE virus antigen. The climatic factors were negatively correlated with minimum infection rate (MIR) for both the species, except mean temperature (P<0.05) for Cx. gelidus.

Interpretation & conclusions:

High abundance of Cx. tritaeniorhynchus and Cx. gelidus was observed compared to other mosquito species in the study area. Detection of JEV antigen in the two species confirmed the maintenance of virus. Appropriate vector control measures need to be taken to reduce the vector abundance.

Formulation and Evaluation of Oral Elementary Osmotic Pump Tablets of Sumatriptan Succinate

Aim: In the present study, Sumatriptan succinate was formulated as oral elementary osmotic pump with a zero-order drug release profile. Methodology: The effect of different formulation variables i.e. different types of osmogens, concentrations of osmogen and concentration of coating solution were studied. The in vitro evaluation was carried out in different release media. Result: Highest percentage of drug release was observed at high concentration of mannitol i.e., 1:3 (drug: mannitol). Osmogen with low osmotic pressure (38 atm) showed 71.01% zero-order drug release for 12 hours when compared to that of the osmogen with high osmotic pressure (356 atm) which showed 67.38% of release by zero order. Conclusion: Elementary osmotic pump tablets of Sumatriptan succinate were able to deliver zero-order release up to 12 hours independent of pH of dissolution media and have overcome the problem of chronotherapeutic effect.

Comparison of the anaesthetic efficacy of different volumes of 4% articaine (1.8 and 3.6 mL) as supplemental buccal infiltration after failed inferior alveolar nerve block

AIM

To compare the anaesthetic efficacy of different volumes (1.8 mL vs. 3.6 mL) of 4% articaine with 1 : 100 000 epinephrine injected as buccal infiltrations after a failed inferior alveolar nerve block (IANB) in patients with symptomatic irreversible pulpitis.

METHODOLOGY

Two hundred and thirty-four adult patients, diagnosed with irreversible pulpitis in a mandibular tooth, participated in this multicentre, randomized double-blinded trial. Patients received IANB with 1.8 mL of 4% articaine with 1 : 100 000 epinephrine. Pain during treatment was recorded using the Heft-Parker visual analogue scale (HP VAS). The primary outcome measure, and the definition of 'success', was the ability to undertake pulp chamber access and canal instrumentation with no or mild pain (HP VAS score <55 mm). Patients who experienced 'moderate-to-severe' pain (HP VAS score ≥ 55 mm) were randomly allocated into two groups and received buccal infiltrations with either 1.8 mL or 3.6 mL of 4% articaine with 1 : 100 000 epinephrine. Root canal treatment was re-initiated after 10 min. Success was again defined as no pain or weak/mild pain during endodontic access preparation and instrumentation. Statistical analysis was performed using Mann-Whitney U and chi-square tests.

RESULTS

The initial IANB of 4% articaine gave an overall success rate of 37%. The success rate of supplementary buccal infiltration with 1.8 and 3.6 mL volumes was 62% and 64%, respectively. The difference between the success rates of the two volumes was not statistically significant.

CONCLUSIONS

Increasing the volume of 4% articaine with 1 : 100 000 epinephrine from 1.8 to 3.6 mL, given as supplementary buccal infiltrations after a failed primary IANB with 1.8 mL of 4% articaine with 1 : 100 000, did not improve the anaesthetic success rates in patients with symptomatic irreversible pulpitis.

An unusual occurrence of bilaterally geminated mandibular second premolars resulting in premolar molarization: A case report

Gemination refers to an attempt by a single tooth bud to divide, with a resultant formation of either a large tooth with a bifid crown or two completely divided teeth throughout the crown and root. This report describes a rare case of bilateral gemination of permanent mandibular second premolar tooth giving rise to molarization of premolars. The mesiodistal width of these teeth is similar to mandibular molars, but the cervicoocclusal width is lesser than that of the molar tooth. This paper also discusses the potential orthodontic, periodontal, and endodontic complications of premolar molarization.

Description of a new species, Toxorhynchites (Toxorhynchites) tyagii (Diptera: Culicidae), from Nilgiri hills, Western Ghats, southern India

Specimens of Toxorhynchites (Toxorhynchites) tyagii, sp. n., were collected from the fringe areas of Gudaloor town, Ooty in the Nilgiri hills at an altitude of 1000 m above sea level in Western Ghats ranges in southern India during October 2011 and from Darjeeling ranges in the northern hilly region of Raymatang TG in Jalpaiguri district, West Bengal, in eastern India during February 2012. The adults, pupa and fourth-instar larva of this species are described and illustrated to distinguish it from Toxorhynchites (Tox.) splendens and Toxorhynchites (Tox.) edwardsi, which are the closest allies of Tx. (Tox.) tyagii. Besides possessing remarkable distinguishing male genital characteristics, Tx. tyagii differs from Tx. splendens also by the presence of conspicuous yellow scale-patches over the wing root that extend to the scutellum, and differs from Tx. edwardsi by having midtarsomeres 3-5 all dark whereas in Tx. edwardsi tarsomeres 3 and 4 and a larger part of 5 are white.

Molecular identification of mosquito vectors using genomic DNA isolated from eggshells, larval and pupal exuvium

Correct and precise identification of mosquito vectors is important in many respects including development of vector control strategies. Conventional identification methods have limitations for sibling and closely related species of mosquitoes, stage and quality of the specimen used and this could be overcome by DNA-based identification methods using molecular markers such as nuclear ribosomal internal transcribed spacer (ITS) which do not demand intact or undamaged specimen. Genomic DNA is usually isolated from whole mosquito, legs, wings etc. Alternate sources for genomic DNA isolation such as eggshells, larval and pupal exuviae were explored in this study by amplifying the ITS markers. Standardization of genomic DNA extraction and ITS amplification were carried out with laboratory specimens. The same was applied to specimens collected from the field. The results show that PCR amenable genomic DNA could be isolated from fresh exuviae collected in the laboratory and not from older and/or field specimens. But exuviae of larvae and/or pupae collected in the field reared to adulthood in the laboratory yielded PCR amenable genomic DNA. The results also revealed that the ITS2 marker could very well differentiate Aedes aegypti and Aedes albopictus by producing amplicons of ~330 bp and ~520 bp, respectively. The genomic DNA from these alternate sources also supported the species-specific PCR to distinguish the Culex vishnui subgroup mosquitoes.

A short, stereoselective, and common approach for the synthesis of 4,5-disubstituted delta-lactones simplactone B and its C-5 analogue

A short, stereoselective, and a common approach for the synthesis of 4,5-disubstituted delta-lactones simplactone B and its analogue using Evans protocol is described.

Hemodynamic monitoring in the neurological intensive care unit

The neurointensivist needs to have a thorough understanding of hemodynamic issues and the interaction of the brain and the cardiovascular system. Before one decides to intervene and try to correct an apparent "abnormal hemodynamic parameter" one needs to think whether such an intervention is indeed warranted and what effect the intervention would have on the cerebral circulation. The neurointensivist thus needs to approach these issues differently from the approach an internist or general intensivist would take.

Acinetobacter sepsis in neonates

Twenty-six neonates were diagnosed to have acinetobacter sepsis during 1986-90, representing 6.5% of all cases of bacteriologically proven sepsis. Of these 19 neonates were low birth weight (LBW) 12 were small for gestational age (SGA). Nineteen neonates had early-onset sepsis. The male to female ratio was 9:17. The hematological profile was suggestive of sepsis in 17 cases. All infants had clinical evidence of multi system infection. Eleven babies died; the cases-fatality rate was 42.3%. Only 15/25 culture isolates were sensitive to gentamicin and resistance to other antibiotics was even more frequent. Acinetobacter was cultured from other sites: eye swabs, skin pustules and umbilical catheter tips. Environmental nursery surveillance cultures done during the study period yielded Acinetobacter once from a crib, but no cases of sepsis occurred around that time. The epidemiological features of this organism illustrate the value of vigilance and precautionary measures.

Prognosis of single unprovoked seizure

201 patients (131 males and 70 females) with mean age of 18 years (range 5-55 years) who presented at median of 6 days after the onset of first unprovoked seizure were studied. They were followed for a mean period of 60 months (range 12-84 months). One hundred and fifty four (76%) patients were treated with anticonvulsant medication (group A) on a non-randomized basis and the remaining 47 patients (24%) were not treated (group B). Both the groups were comparable for age, sex, type of seizure and interval between onset of seizure and consultation. The cumulative risk of recurrence for entire study group was 24% at 1 month, 32% at 6 months, 34% at 12 months, 35% at 24 months and 36% at 36 months. The cumulative risk of recurrence in group A was 23%, 30%, 32%, 33% and 33% as compared to 28%, 36%, 40%, 43% and 45% at 1, 6, 12, 24 and 36 months respectively (p > 0.05). Maximum number of recurrences (67%) occurred within 1 month. No recurrence occurred after 36 months after the onset of first seizure. Age at onset, sex, seizure type, family history of seizure, EEG abnormalities and nature of antiepileptic drugs did not influence the risk of recurrence.

Rotavirus and bacterial enteropathogens causing acute diarrhea

The etiology of rotavirus in acute diarrhoeal illness in children 0-5 years of age, admitted to the Pediatric wards of Kasturba Medical College Hospital, Manipal was studied, over a period of one year. Rotavirus in the faecal samples detected by the slide latex agglutination test accounted for 14.9% of the diarrheas with maximum incidence in the 7-12 months of age group (57.5%). Bacterial enteropathogens continued to play a significant role in diarrheal diseases. Salmonella enteritis was found more in the age group 0-6 months and shigellosis in 37-60 months. In a control study of 100 children who had no diarrhea, 2 were found positive for rotaviruses.

Computerised neonatal case records: a four year experience

A computerized system for neonatal case records has been used for the last four years at Kasturba Hospital. The software was developed in-house. The data base can be used to generate discharge summaries, neonatal statistics and epidemiological information. For a single patient, entry of data and printing of the discharge summary takes four to five minutes. Consolidated demographic and epidemiological statistics or selective clinical data for clinical research is easily retrievable. The system is efficient, accurate and easy to operate.

Quantitation of proteinuria using protein-creatinine ratio in random urine samples

Estimation of proteinuria in children is cumbersome when a 24 h urine collection is needed. In the presence of a stable glomerular filtration rate, the ratio of urinary protein and creatinine should reflect the protein excretion. One hundred samples of urine (24 h and random samples) were collected from 50 children with nephrotic syndrome, 25 with nephrotic syndrome in remission and 25 normal children. The 24 h urine total protein and random urine protein-creatinine ratio were assessed on these samples. Linear regression analysis of the results showed excellent correlation between the values (r = 0.81, p less than 0.001). A random urine protein-creatinine ratio of greater than 3.5 correlated with massive proteinuria, while a ratio less than 0.2 was suggestive of physiological values. The sensitivity, specificity, positive and negative predictive values of the protein-creatinine ratio in massive proteinuria were very high. We conclude that the random urine protein-creatinine ratio can be used reliably to assess the degree of proteinuria in children.

Salmonella typhimurium isolated from bacteraemia

During a two year period, a total of 15 strains of S. typhimurium were isolated and analysed by phage typing. Of these, 13 were found untypable, while two strains belonged to phage 76 and 22. All the strains were sensitive to Gentamicin and Cephaloridine. All but one showed multiple drug resistance.

Neonatal citrobacter sepsis: clinical and epidemiological aspects

Fourteen neonates were diagnosed to have Citrobacter sepsis during 1986-89, representing 4.6% of all cases with bacteriologically proven sepsis. Most of these infants were low birth weight (mean 2046 gm, +/- 750) and preterm (mean 34.8 weeks, +/- 3.8). Mean age at onset of sepsis was five days. In 10 cases the hematological profile was suggestive of sepsis. Infants had clinical evidence of multisystem infection; 2 with septic arthritis and 3 meningitis. The case fatality rate was 61%. Resistance to antibiotics was frequent. Citrobacter species were also cultured from other sites: umbilical stumps, eye swabs, urine, skin pustules and umbilical catheter tips. The epidemiological features and virulence of this organism call for vigilance and strict control measures.

Pediatric cancer care in India. A national survey

A national survey of institutions treating children with cancer was undertaken in April 1988. The 21-item questionnaire included questions on personnel, treatment facilities, support services, attitudes and opinions regarding pediatric cancer care. 73 institutions responded. From the survey, it emerged that pediatricians did not see all pediatric patients with cancer at one-third of the respondent institutions. 50 percent of cancer centres did not have pediatricians. Cancer centres were better staffed with specialist personnel and better support services. Respondents felt that pediatric oncologists and specialist support personnel were necessary for optimal pediatric cancer care and facilities at medical colleges needed to be improved because of the large number of children with cancer treated at these institutions.

Serum apolipoproteins A and B, lecithin: cholesterol acyl transferase activities and urinary cholesterol levels in nephrotic syndrome patients before and during steroid treatment

Serum apolipoproteins A (Apo-A) and B (Apo-B) and lecithin: cholesterol acyl transferase (LCAT) activities and 24-hour urinary cholesterol levels were estimated in 25 nephrotic children before and during steroid treatment with 4 weeks of daily prednisolone followed by another 4 weeks of alternate-day prednisolone. The patients with untreated nephrotic syndrome (NS) showed significant decrease in serum Apo-A and LCAT activities associated with significant increase in serum Apo-B and urinary cholesterol levels compared to healthy controls (n = 25). Serum Apo-A levels correlated directly and Apo-B levels inversely with the serum albumin concentrations. After a transient elevation, the serum Apo-A level returned to control range by 8 weeks of treatment accompanied by a gradual increase in serum LCAT activity and decrease in urinary cholesterol excretion. Though, the serum Apo-B level was decreased with treatment, it was still significantly high compared to the controls.

Neonatal behavior of small for gestational age infants

The behavioral pattern of small for gestational age (SGA) infants differs from that of appropriate for gestational age (AGA) infants. Maternal malnutrition and SGA infants being a common problem in our country, we assessed the behavior of 36 full term SGA infants using the Brazelton scale. These infants had an excellent orienting capacity, state control and self quieting. Their motor performance was fair and autonomic regulation showed a good recovery over first 10 days. A comparison of this behavior with full term AGA infants showed a better orientation in SGA infants. Though there was a significant difference in motor, state regulation, and autonomic regulation, by the end of the first month they recovered to the same level as the AGA infants. The pattern of SGA behavior described is at marked variance with most of other reports from abroad.

Intraperitoneal ascariasis

Seven children with intraperitoneal ascariasis are reported. One of them had two episodes. There were four instances of free worms in the peritoneal cavity, whereas others had peritoneal abscesses containing round worms. It is suggested that peritoneal ascariasis should be suspected whenever a child presents with peritonitis and/or an inflammatory abdominal mass having evidence of ascarial infestation.