Vaccine Safety Datalink infrastructure enhancements for evaluating the safety of maternal vaccination

BACKGROUND

Identifying pregnancy episodes and accurately estimating their beginning and end dates are imperative for observational maternal vaccine safety studies using electronic health record (EHR) data.

METHODS

We modified the Vaccine Safety Datalink (VSD) Pregnancy Episode Algorithm (PEA) to include both the International Classification of Disease, ninth revision (ICD-9 system) and ICD-10 diagnosis codes, incorporated additional gestational age data, and validated this enhanced algorithm with manual medical record review. We also developed the new Dynamic Pregnancy Algorithm (DPA) to identify pregnancy episodes in real time.

RESULTS

Around 75% of the pregnancy episodes identified by the enhanced VSD PEA were live births, 12% were spontaneous abortions (SABs), 10% were induced abortions (IABs), and 0.4% were stillbirths (SBs). Gestational age was identified for 99% of live births, 89% of SBs, 69% of SABs, and 42% of IABs. Agreement between the PEA-assigned and abstractor-identified pregnancy outcome and outcome date was 100% for live births, but was lower for pregnancy losses. When gestational age was available in the medical record, the agreement was higher for live births (97%), but lower for pregnancy losses (75%). The DPA demonstrated strong concordance with the PEA and identified pregnancy episodes ⩾6 months prior to the outcome date for 89% of live births.

CONCLUSION

The enhanced VSD PEA is a useful tool for identifying pregnancy episodes in EHR databases. The DPA improves the timeliness of pregnancy identification and can be used for near real-time maternal vaccine safety studies.

PLAIN LANGUAGE SUMMARY

Improving identification of pregnancies in the Vaccine Safety Datalink electronic medical record databases to allow for better and faster monitoring of vaccination safety during pregnancy Introduction: It is important to monitor of the safety of vaccines after they have been approved and licensed by the Food and Drug Administration, especially among women vaccinated during pregnancy. The Vaccine Safety Datalink (VSD) monitors vaccine safety through observational studies within large databases of electronic medical records. Since 2012, VSD researchers have used an algorithm called the Pregnancy Episode Algorithm (PEA) to identify the medical records of women who have been pregnant. Researchers then use these medical records to study whether receiving a particular vaccine is linked to any negative outcomes for the woman or her child.Methods: The goal of this study was to update and enhance the PEA to include the full set of medical record diagnostic codes [both from the older International Classification of Disease, ninth revision (ICD-9 system) and the newer ICD-10 system] and to incorporate additional sources of data about gestational age. To ensure the validity of the PEA following these enhancements, we manually reviewed medical records and compared the results with the algorithm. We also developed a new algorithm, the Dynamic Pregnancy Algorithm (DPA), to identify women earlier in pregnancy, allowing us to conduct more timely vaccine safety assessments.Results: The new version of the PEA identified 2,485,410 pregnancies in the VSD database. The enhanced algorithm more precisely estimated the beginning of pregnancies, especially those that did not result in live births, due to the new sources of gestational age data.Conclusion: Our new algorithm, the DPA, was successful at identifying pregnancies earlier in gestation than the PEA. The enhanced PEA and the new DPA will allow us to better evaluate the safety of current and future vaccinations administered during or around the time of pregnancy.

Retention of enrollees following a cancer diagnosis within health maintenance organizations in the Cancer Research Network

Population laboratories with complete clinical information on episodes of care are needed to support research on the quality of care delivered to cancer patients. Data resources within the Cancer Research Network (CRN) may overcome many of the limitations of existing cancer databases, but their potential clinical value depends on the stability of the enrolled population. To assess this issue, we studied the retention rates among survivors of the 132 580 patients diagnosed with cancer from January 1, 1993, through December 31, 1998, who were enrolled at five health maintenance organization sites participating in the CRN. Enrollees were followed from cancer diagnosis through death, disenrollment, or the end of follow-up (i.e., December 31, 1999). The retention rate among survivors for all cancers combined at 1 and 5 years after cancer diagnosis was 96.0% (95% confidence interval [CI] = 95.9% to 96.1%) and 83.9% (95% CI = 83.4% to 84.3%), respectively. The proportion of enrollees diagnosed with cancer who remained enrolled and available for evaluation suggests that the CRN is well-suited for studies of the quality of care for cancer patients, survivorship, and long-term outcomes.

Airbag injuries in infants and children: a case report and review of the literature

Airbags have saved an estimated 2620 lives as of November 1997. However, airbags also have caused a number of injuries and deaths and have received a lot of publicity from the NHTSA and the media as a result. The majority of the injuries have occurred when seat belts and shoulder harnesses were not used properly in conjunction with airbags. This article describes an injury that apparently occurred despite use of an age-appropriate, state-of-the-art child protection seat.

Acupuncture in the treatment of paralysis in chronic and acute stroke patients--improvement correlated with specific CT scan lesion sites

A total of 20 stroke patients received acupuncture, including 10 chronic and 10 acute patients; 19 of the 20 patients (95%) could be correctly classified regarding beneficial response to acupuncture, versus poor response, based on CT scan lesion site data, alone. Patients with beneficial response had damage to less than half of the motor pathway areas on CT scan, especially in the periventricular white matter area (PVWM) at the level of the body of the lateral ventricle. Overall, 8 of the 20 patients receiving acupuncture had beneficial response with measurable objective improvement in motor function, including 3 of the 10 chronic patients treated at > 3 months poststroke, and 5 of the 10 acute patients treated at < 3 months poststroke. Among the 8 patients with beneficial response, significant improvements were observed in knee flexion, knee extension, and shoulder abduction. Neither age, nor months poststroke when acupuncture was begun, was significantly correlated with the total number of improved tests, post-acupuncture. Two chronic patients with beneficial response first began receiving acupuncture at 3 years and 6 years poststroke. Most improvements were sustained for at least 4 months after the last acupuncture treatment.

Behavioral Intensive Care Unit (BICU): a new concept in the management of acute agitated behavior in elderly demented patients

Intensive care units were developed in response to the perceived need for increased monitoring in critically ill medical patients. The same principle applies to elderly patients with severe agitated behaviors. These patients can be served by the Geriatric Behavioral Intensive Care Unit (BICU). The uniqueness of the program results from the application of a behavioral and environmental approach to the treatment of agitated behavior. The underlying strategy in the treatment process is to enhance the patient's ability to adapt to his or her home environment. Preliminary results have been encouraging, showing positive outcomes in diverse areas such as low level of institutional placement, patient quality of life, and caregiver symptoms of burden and depression.

Utility of serum interleukin-6 for diagnosis of invasive bacterial disease in children

STUDY OBJECTIVE

To evaluate measurement of interleukin-6 as a diagnostic test for the presence and severity of invasive bacterial disease.

DESIGN

Prospective measurement of interleukin-6 in children with signs of sepsis. (Controls, retrospective from serum bank.)

SETTING

Emergency department of an urban children's hospital.

PARTICIPANTS

Twenty children with clinical signs of sepsis and 50 other febrile infants and toddlers with negative blood cultures.

RESULTS

Eleven of the 20 patients had bacteriologically documented infections: four with meningitis and two with bacteremia caused by Neisseria meningitidis, three with meningitis caused by Haemophilus influenzae type b, and one each with meningitis and bacteremia caused by Streptococcus pneumoniae. Ten of these 11 had detectable interleukin-6. The geometric mean interleukin-6 level in these culture-positive patients was 407 pg/mL (95% confidence interval, 108 to 1,545); all three children with levels of more than 300 pg/mL developed septic shock, and one died. One of nine culture-negative patients with clinical signs of sepsis had detectable serum interleukin-6 (166 pg/mL), but none of 50 other febrile children without occult bacteremia did. The detection of interleukin-6 had a sensitivity of 91% and a specificity of 98% for invasive bacterial disease.

CONCLUSION

High levels of interleukin-6 occur in children with septic shock, and the presence of interleukin-6 in serum is predictive for the isolation of bacteria from blood and/or spinal fluid.

Arterial access in the pediatric emergency department

Arterial catheters are used frequently to monitor critically ill children in ICUs, but their role in the emergency department has not been described. The medical records of all patients admitted to the ICU from the ED of a children's hospital during a 30-month period were reviewed retrospectively. Forty-one patients were identified as having arterial catheters placed in the ED. Catheterization was performed for serial blood gas determinations (59%) or continuous blood pressure monitoring (41%). The radial artery was catheterized in 73% of the 41 patients, and a 22-gauge catheter was used in 78% of the patients. The original catheter was discontinued before the end of medical indication in only 24% of cases--17% were discontinued for failure to draw and 7% for vascular changes at the site of the catheter. We conclude that arterial access can be used for children in the ED to monitor blood pressure and that blood gas tensions and complications are few and generally minor.

Effect of bacille Calmette-Guerin immunotherapy on feline sarcoma virus-induced neoplasms in the cat

Kittens infected experimentally with feline sarcoma virus (FeSV) were inoculated with emulsions of bacille Calmette-Guerin (BCG) cell wall preparations to determine the effect of BCG immunotherapy on FeSV-induced sarcoma-genesis. The BCG preparations or emulsificant control preparations were administered (i) subcutaneously at the same time and site as was the FeSV inoculation, (ii) at the same site but 1 week after FeSV inoculation, or (iii) with a mixture of viable autochthonous neoplastic cells approximately 35 days after FeSV inoculation. There was no difference in the percentage of kittens that developed neoplasms, the prepatent period for neoplastic development, the percentage of kittens with neoplastic regression, or the survival rate among groups given BCG, emulsificant control, or FeSV alone. Significantly (P less than 0.05) greater dissemination of neoplasms was seen in groups given BCG or emulsificant control preparations, compared with dissemination in groups given FeSV alone.

Neurofibromatosis in monozygotic twins: a case report of spontaneous mutation

We report female monozygotic twins with neurofibromatosis. The family history is unremarkable, and careful examination of other family members did not show evidence of the condition. It is concluded that the occurrence in this family is due to a spontaneous mutation arising in one of the parental gametes. This article examines the similarity and difference in manifestations of the disorder in this pair of monozygotic twins.

Fatal infantile mitochondrial myopathy and renal dysfunction due to cytochrome-c-oxidase deficiency

A 1-month-old boy was admitted because of failure to thrive. He was floppy and had bilateral ptosis, diminished reflexes, and poor suck. He had aspiration pneumonia, developed seizures, and died at age 3 1/2 months. Laboratory data showed lactic acidosis, proteinuria, glycosuria and generalized aminoaciduria. He was an only child, and family history was negative. Muscle biopsy showed large clumps of granules positive with oxidative enzyme stains and increased lipid droplets. Ultrastructural studies showed large aggregates of mitochondria, many of which were greatly enlarged and contained disoriented or concentric whorls of cristae and paracrystalline inclusions. Cytochrome c oxidase was absent in fresh frozen sections by histochemical staining. By biochemical assay, cytochrome c oxidase (cytochrome aa3) was 6% of normal in muscle biopsy and undetectable in autopsy muscle; spectra and content of cytochromes showed lack of cytochrome aa3, decreased cytochrome b and normal cytochrome cc1. In kidney, cytochrome-c-oxidase activity was 38% of normal and spectra showed decreased cytochromes aa3 and b. The association of fatal infantile mitochondrial myopathy, lactic acidosis and renal dysfunction was previously reported by Van Biervliet et al and appears to be a distinct nosologic entity, one of the few biochemically defined mitochondrial myopathies.

Medical Aspects of Distance Race Planning

Physicians should help set the standards for medical care at long-distance races. The authors recommend that runners be educated, and they set guidelines for aid stations and paramedical personnel.

Professional Basketball Players: Athletic Profiles

The physical characteristics of basketball players are closely related to their position on the team, according to this study. The authors believe this type of information would be useful in the selection and training of players.

Pulmonary metastases from benign-appearing smooth muscle tumors of the uterus

A 42-year-old woman was found to have multiple pulmonary nodules 7 years after hysterectomy for leiomyoma. Thoracotomy revealed multiple well differentiated smooth muscle masses containing epithelial inclusions. This patient is similar to others previously reported as examples of "multiple pulmonary fibroleiomyomatous hamartoma" on the basis of slow-growth, benign-appearing histology, and the presence of epithelial elements. Evidence is presented which suggests that these cases represent metastasis from well differentiated leiomyosarcomas. There is a frequent association with uterine smooth-muscle tumor, cases with equally benign-appearing histology have shown lymph node metastasis, the nonmesenchymal elements have been shown to represent engulphed bits of adjacent pulmonary tissue, and the histologic di-ferentiation of benign from malignant mesenchymal tumors is known to be unreliable in some cases. Unlike more anaplastic leiomyosarcomas, this condition may be associated with few symptoms and prolonged survival despite widespread disease.