Validation of medical service insurance claims as a surrogate for ascertaining vitiligo cases

The epidemiology of vitiligo, especially its disease burden on the healthcare system, can be assessed indirectly by analyzing health insurance claims data. Validating this approach is integral to ensuring accurate case identification and cohort characterization. The primary aim of this study was to develop and validate an indirect measure of vitiligo ascertainment using health insurance claims data. These data were used secondarily to identify demographic characteristics, body site involvement, vitiligo subtypes, disease associations, and treatments. This study assessed the validity of identifying vitiligo from billing claims within a Canadian provincial universal health insurance program, versus vitiligo cases accrued from direct medical chart reviews. Claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment-specific data were derived and tested to identify vitiligo patients. This was compared against cases arising from the manual review of medical records of 606 patient with a diagnostic code for "dyschromia" (ICD-9-CM diagnostic code 709) from January 1 to December 31, 2016. Based on the chart reviews, 204 (33.7%) patients were confirmed to have vitiligo. 42 separate claims-based algorithms combining ICD-9-CM diagnostic code 709 with treatment data specific to vitiligo were modeled and individually tested to evaluate their accuracy for vitiligo ascertainment. One algorithm achieved a sensitivity, specificity, PPV and NPV of 86.8% (95% CI 82.1-91.4), 92.5% (95% CI 90.0-95.1), 85.5% (95% CI 80.7-90.3), and 93.2% (95% CI 90.8-95.7), respectively. There was a 2.2 female-to-male ratio. The most common medical treatments were tacrolimus (74.5%) and topical corticosteroids (54.3%). Hypertension (24.2%) and hypothyroidism (19.6%) were the predominant co-morbidities associated with vitiligo. Health insurance claims data can be used to indirectly ascertain vitiligo for epidemiologic purposes with relatively high diagnostic performance between 85.5 and 93.2%.

Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites

Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.

Correlation between Cranial Nerve Microstructural Characteristics and Vestibular Schwannoma Tumor Volume

BACKGROUND AND PURPOSE

Vestibular schwannomas are common cerebellopontine angle tumors arising from the vestibulocochlear nerve and can result in cranial nerve dysfunction. Conventional MR imaging does not provide information that could correlate with cranial nerve compression symptoms of hearing loss or imbalance. We used multitensor tractography to evaluate the relationship between the WM microstructural properties of cranial nerves and tumor volume in a cohort of patients with vestibular schwannomas.

MATERIALS AND METHODS

A retrospective study was performed in 258 patients with vestibular schwannomas treated at the Gamma Knife clinic at Toronto Western Hospital between 2014 and 2018. 3T MR images were analyzed in 160 surgically naïve patients with unilateral vestibular schwannomas. Multitensor tractography was used to extract DTI-derived metrics (fractional anisotropy and radial, axial, and mean diffusivities of the bilateral facial and vestibulocochlear nerves [cranial nerves VII/VIII]). ROIs were placed in the transition between cisternal and intracanalicular segments, and images were analyzed using the eXtended Streamline Tractography reconstruction method. Diffusion metrics were correlated with 3D tumor volume derived from the Gamma Knife clinic.

RESULTS

DTI analyses revealed significantly higher fractional anisotropy values and a reduction in axial diffusivity, radial diffusivity, and mean diffusivity (all P < .001) within the affected cranial nerves VII and VIII compared with unaffected side. All specific diffusivities (axial, radial, and mean diffusivity) demonstrated an inverse correlation with tumor volume (axial, radial, and mean diffusivity, P < .01).

CONCLUSIONS

Multitensor tractography allows the quantification of cranial nerve VII and VIII WM microstructural alterations in patients with vestibular schwannomas. Our findings support the hypothesis that tumor volume may cause microstructural alterations of the affected cranial nerves VII and VIII. This type of advanced imaging may represent a possible avenue to correlate diffusivities with cranial nerve function.

Isolated distal adductor magnus tendon avulsion as a rare cause of medial knee pain. A case report

Avulsion injuries of adductor frequently involve the proximal origin. We report the first case of avulsion fracture of adductor magnus at its insertion and discuss the relevant anatomy.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

Background

Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed.

Methods

This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER’s processes.

Conclusion

We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement.

Trial registration

Clinicaltrials.gov NCT03689049; registered September 28, 2018

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0904-4) contains supplementary material, which is available to authorized users.

Current status on mapping of genes for resistance to leaf- and neck-blast disease in rice

Blast disease caused by fungal pathogen Pyricularia oryzae is a major threat to rice productivity worldwide. The rice-blast pathogen can infect both leaves and panicle neck nodes. Nearly, 118 genes for resistance to leaf blast have been identified and 25 of these have been molecularly characterized. A great majority of these genes encode nucleotide-binding site-leucine-rich repeat (NBS-LRR) proteins and are organized into clusters as allelic or tightly linked genes. Compared to ever expanding list of leaf-blast-resistance genes, a few major genes mediating protection to neck blast have been identified. A great majority of the genetic studies conducted with the genotypes differing in the degree of susceptibility/resistance to neck blast have suggested quantitative inheritance for the trait. Several reports on co-localization of gene/QTLs for leaf- and neck-blast resistance in rice genome have suggested the existence of common genes for resistance to both phases of the disease albeit inconsistencies in the genomic positions leaf- and neck-blast-resistance genes in some instances have presented the contrasting scenario. There is a strong evidence to suggest that developmentally regulated expression of many blast-resistance genes is a key determinant deciding their effectiveness against leaf or neck blast. Testing of currently characterized leaf-blast-resistance genes for their reaction to neck blast is required to expand the existing repertoire resistance genes against neck blast. Current developments in the understanding of molecular basis of host-pathogen interactions in rice-blast pathosystem offer novel possibilities for achieving durable resistance to blast through exploitation of natural or genetically engineered loss-of-function alleles of host susceptibility genes.

A feature fusion system for basal cell carcinoma detection through data-driven feature learning and patient profile

BACKGROUND

Basal cell carcinoma (BCC) is the most common skin cancer, which is highly damaging in its advanced stages. Computer-aided techniques provide a feasible option for early detection of BCC. However, automated BCC detection techniques immensely rely on handcrafting high-level precise features. Such features are not only computationally complex to design but can also represent a very limited aspect of the lesion characteristics. This paper proposes an automated BCC detection technique that directly learns the features from image data, eliminating the need for handcrafted feature design.

METHODS

The proposed method is composed of 2 parts. First, an unsupervised feature learning framework is proposed which attempts to learn hidden characteristics of the data including vascular patterns directly from the images. This is done through the design of a sparse autoencoder (SAE). After the unsupervised learning, we treat each of the learned kernel weights of the SAE as a filter. Convolving each filter with the lesion image yields a feature map. Feature maps are condensed to reduce the dimensionality and are further integrated with patient profile information. The overall features are then fed into a softmax classifier for BCC classification.

RESULTS

On a set of 1199 BCC images, the proposed framework achieved an area under the curve of 91.1%, while the visualization of learned features confirmed meaningful clinical interpretation of the features.

CONCLUSION

The proposed framework provides a non-invasive fast BCC detection tool that incorporates both dermoscopic lesional features and clinical patient information, without the need for complex handcrafted feature extraction.

Cigarette smoking among adolescent females in Pakistan

SETTING

Tobacco use among adolescent females is gaining importance as they take up smoking in increasing numbers. Recent studies show that sex differences in tobacco use are disappearing and that tobacco companies are agressively targeting females in developing countries.

OBJECTIVE

To determine the factors influencing the use of cigarettes among female high-school students in Karachi, Pakistan, and hence to identify areas for future intervention.

METHOD

A two-stage cluster sample of 644 females was drawn from government and private schools in a locality in Karachi. A self-administered questionnaire was used for data collection.

RESULTS

The mean age was 15.29 years. The prevalence of ever-smokers was found to be 16.3%. Univariate analysis indicated that private school attendance, underage sale of tobacco at shops, tobacco use by family members and exposure to cigarette advertisements predicted smoking among girls. Knowledge assessment of the subjects showed that most girls had good knowledge about the hazards of smoking.

CONCLUSION

Our study has identified several risk factors for smoking among young girls. Appropriate interventions are needed in the form of public education programmes, effective anti-tobacco laws and stricter enforcement of existing laws to restrict the number of young female smokers.

Influence of steroid drugs on orthodontically induced root resorption

OBJECTIVES

To investigate the effect of acute and chronic corticosteroid treatment on orthodontically induced root resorption.

DESIGN

'Split mouth' design performing orthodontic tooth movement in 64, 6-month-old male rats divided into three groups: acute (n = 22), chronic (n = 23) and control group (n = 19). Acute and chronic group received corticosteroid treatment (8 mg/kg/day) for 3 and 7 weeks, respectively, while no pharmacological treatment was performed in the control group. Performed at the Department of Orthodontics, School of Dentistry, University of Aarhus, Aarhus, Denmark.

EXPERIMENTAL VARIABLE

The upper left first molar was moved mesially for 21 days in all three groups with 25 g of force. Undecalcified histological sections were cut at the coronal and apical level.

OUTCOME MEASURE

The number of intersections hitting resorption lacunae (ES), defined as a scalloped surface with or without cementoclasts, over the total number of intersections hitting the root surface (RS) were recorded and expressed as percentage.

RESULTS

The acute group showed significantly more root resorption at the mesio-coronal level compared with the control and the chronic group.

CONCLUSION

This could be ascribed to the lack of balance between blastic activities (inhibited by the drug) and the clastic activities (enhanced or unchanged by drug administration) occurring in the initial phase of drug administration. As a consequence, a careful monitoring of patients undergoing acute corticosteroid treatment is suggested.

Tissue reaction to orthodontic tooth movement in acute and chronic corticosteroid treatment*

OBJECTIVES

To study tissue reaction to orthodontic loading during the course of short- and long-term corticosteroid administration.

DESIGN

'Split-mouth' design to perform orthodontic tooth movement in 64 six-month-old male rats divided into groups: no drug administration (n = 19), acute (n = 22) and chronic (n = 23) 8 mg/kg/day corticosteroid treatment. Performed in the Department of Orthodontics at Aarhus University.

EXPERIMENTAL VARIABLE

The upper left first molar was moved for 21 days. Bone markers were administered at 7 and 2 days before sacrifice. Histological sections were cut at the coronal level.

OUTCOME MEASURE

Tooth movement rate, alveolar socket area, the relative extension of alveolar wall with erosion, and the mineralizing surfaces were measured and compared in the three groups.

RESULTS

Tooth movement rate increased in the chronic group. The mechanical load induced an enlargement of the alveolar wall that was less pronounced in both medicated groups. In the acute group the drug suppressed bone resorption and formation without mechanical stimulus. Force application resulted in significant increase in the relative extension of resorption and formation in both drug groups; it was particularly pronounced in the chronic group.

CONCLUSION

Because acute corticosteroid ingestion reduces bone turnover, in these patients orthodontic treatment might best be postponed until a time the patient is free of the drug. Chronic steroid ingestion leads to an increased biological reaction to mechanical perturbation indicating that the orthodontic force level should be reduced and controlled more frequently in patients on chronic steroid treatment.

Minimal promoter for the NAD+-specific glutamate dehydrogenase gene of Neurospora crassa

The expression of the NAD+-specific glutamate dehydrogenase (NAD-GDH) gene of Neurospora crassa is subject to catabolite repression. To identify the minimal sequence necessary for promoter function, the 5'-flanking region of the NAD-GDH gene was screened for potential protein-binding sites. Fragments of DNA, containing sequences upstream from the ATG initiation codon, were employed as probes of Southwestern blots of total cellular protein from cells grown in media promoting repression and induction of NAD-GDH. Two polypeptides interacted differentially with a promoter probe; one was present in greater abundance in repressed cells and a higher relative level of the second was witnessed in induced cells. Electrophoretic mobility shift assays with labeled promoter fragments exhibited preferential interaction with proteins in the induced cultures. The upstream sequence containing the putative protein-binding sites was fused with the coding sequence of the green fluorescent protein (GFP). The resulting plasmid was introduced into the microconidia of an albino mutant of N. crassa by electroporation. Stable integration of the plasmid and_expression of GFP in the hyphae and conidia of the transformants were demonstrated by Southern and Western blot analysis and fluorescence microscopy.

Interdisciplinary approaches to adult orthodontic care

The orthodontic treatment of adult patients is most frequently just one component of a more complex treatment involving several dental disciplines. This report discusses the potential problems related to the establishment of a treatment plan and the necessity for the patient's full acceptance, and understanding of the pros and cons related to different treatment approaches. In addition, the case report underlines the importance of a well-defined treatment goal. We have illustrated the team approach and the treatment principles in this combined perio-, ortho-, and prosthodontic patient.

Establishment of synchronization in carrot cell suspension culture and studies on stage specific activation of glyoxalase I

The present report summarizes and compares the effects of three cell cycle inhibitors, viz. aphidicolin, hydroxyurea and mimosine, in inducing synchronization of a rapidly proliferating suspension culture of carrot. These treatments efficiently synchronized the cell cycle as the doubling time of the cell population was roughly equal to the total length of one cell cycle. Protoplasts derived from mimosine treated cell suspension culture were resolved via flow cytometry to get an idea of the temporal organization of the cell cycle events. The biochemical analysis showed a rise in stage specific activity of glyoxalase I, an auxin inducible marker enzyme activated at G2-M. This activity peak could be shifted to an early phase of interphase in response to auxin treatment.

Emergency evaluation of the cancer patient

The oncology patient can experience medical or surgical emergencies as a result of effects of the primary tumor, metastases, or systemic effects of the disease. Emergencies unrelated to the primary oncologic diagnosis, such as acute myocardial infarction, drug overdose, or gastrointestinal hemorrhage, also may occur. For this reason routine emergency protocols and diagnostic procedures should be followed in the treatment of oncology patients. We review the major oncologic-related emergencies, including central nervous system and spinal cord compression, airway obstruction, cardiac tamponade, gastrointestinal obstruction, adrenal insufficiency and hypercalcemia, sepsis, and coagulopathies. Medical and surgical emergencies in the oncology patient should be treated aggressively in the emergency department because a determination about the quality of life of the patient, or the reversibility of the acute process, often cannot be answered quickly in the emergency setting.