Influence of Breast Cancer and Metastases on Incidence of Diabete

Purpose: Diabetes increases the risk of subsequent breast cancer. However, the inverse relationship of breast cancer to incident diabetes development is unclear. In preclinical models increased bone turnover due to bone metastases or endocrine therapies impacts insulin secretion. This analysis was conducted to estimate the incidence of diabetes after breast cancer and the influence of metastases and therapeutic agents. Methods: This retrospective case-control study combined data from a large electronic health data exchange and the Indiana State Cancer Registry on breast cancer patients and controls between 2007 and 2017. Primary exposure was presence of breast cancer and bone or non-bone metastases. The primary outcome was frequency of incident diabetes detected by ICD codes, medication use, or laboratory results, compared between breast cancer cases and controls using conditional or ordinary logistic regressions. Results: 36,083 cases and 36,083 matched controls were detected. Incident diabetes was higher in early stage breast cancer (OR 1.17, 95%CI 1.11-1.23, p<0.0001) and metastatic breast cancer (OR 1.62, 95% CI 1.25-2.09, p=0.0002), compared to controls. Bone metastases conferred higher odds of both pre-existing (OR 1.20, 95% CI 1.03-1.63, p=0.0272) and incident diabetes (OR 1.64, 95% CI 1.19-2.25, p=0.0021). Endocrine therapy was associated with reduced diabetes (OR 0.86, 95% CI 0.79-0.83, p=0.002). Anti-resorptives reduced incident diabetes in those with bone metastases (OR 0.44, 95% CI 0.25-0.78, p=0.005). Conclusion: Breast cancer, especially with metastases, increases subsequent risk of diabetes. As patients with breast cancer live longer, identifying and managing diabetes may impact treatment delivery, cost, survival, and quality of life

Provider Adherence to Syphilis Testing Guidelines Among Stillbirth Cases

Background The Centers for Disease Control and Prevention (CDC) recommends that all women with a stillbirth have a syphilis test after delivery. Our study seeks to evaluate adherence to CDC guidelines for syphilis screening among women with a stillbirth delivery. Methods We utilized data recorded in electronic health records for women who gave birth between January 1, 2014 and December 31, 2016. Patients were included if they were 18-44 years old and possessed an ICD-9-CM or ICD-10-CM diagnosis of stillbirth. Stillbirth diagnoses were confirmed through a random sample of medical chart reviews. To evaluate syphilis screening, we estimated the proportion of women who received syphilis testing within 300 days before stillbirth, within 30 days after a stillbirth delivery, and women who received syphilis testing both before and after stillbirth delivery. Results We identified 1,111 stillbirths among a population of 865,429 unique women with encounter data available from electronic health records. Among a sample of 127 chart reviewed cases, only 35 (27.6%) were confirmed stillbirth cases, 45 (35.4%) possible stillbirth cases, 39 (30.7%) cases of miscarriage, and 8 (6.3%) cases of live births. Among confirmed stillbirth cases, 51.4% had any syphilis testing conducted, 31.4% had testing before their stillbirth delivery, 42.9% had testing after the delivery, and only 22.9% had testing before and after delivery. Conclusions A majority of women with a stillbirth delivery do not receive syphilis screening adherent to CDC guidelines. Stillbirth ICD codes do not accurately identify cases of stillbirth

Sarcopenia, frailty and cachexia patients detected in a multisystem electronic health record database

Background: Sarcopenia, cachexia and frailty have overlapping features and clinical consequences, but often go unrecognized. The objective was to detect patients described by clinicians as having sarcopenia, cachexia or frailty within electronic health records (EHR) and compare clinical variables between cases and matched controls. Methods: We conducted a case-control study using retrospective data from the Indiana Network for Patient Care multi-health system database from 2016 to 2017. The computable phenotype combined ICD codes for sarcopenia, cachexia and frailty, with clinical note text terms for sarcopenia, cachexia and frailty detected using natural language processing. Cases with these codes or text terms were matched to controls without these codes or text terms matched on birth year, sex and race. Two physicians reviewed EHR for all cases and a subset of controls. Comorbidity codes, laboratory values, and other coded clinical variables were compared between groups using Wilcoxon matched-pair sign-rank test for continuous variables and conditional logistic regression for binary variables. Results: Cohorts of 9594 cases and 9594 matched controls were generated. Cases were 59% female, 69% white, and a median (1st, 3rd quartiles) age 74.9 (62.2, 84.8) years. Most cases were detected by text terms without ICD codes n = 8285 (86.4%). All cases detected by ICD codes (total n = 1309) also had supportive text terms. Overall 1496 (15.6%) had concurrent terms or codes for two or more of the three conditions (sarcopenia, cachexia or frailty). Of text term occurrence, 97% were used positively for sarcopenia, 90% for cachexia, and 95% for frailty. The remaining occurrences were negative uses of the terms or applied to someone other than the patient. Cases had lower body mass index, albumin and prealbumin, and significantly higher odds ratios for diabetes, hypertension, cardiovascular and peripheral vascular diseases, chronic kidney disease, liver disease, malignancy, osteoporosis and fractures (all p < 0.05). Cases were more likely to be prescribed appetite stimulants and caloric supplements. Conclusions: Patients detected with a computable phenotype for sarcopenia, cachexia and frailty differed from controls in several important clinical variables. Potential uses include detection among clinical cohorts for targeting recruitment for research and interventions

Validation of ICD-10-CM Codes for Identifying Cases of Chlamydia and Gonorrhea

Background While researchers seek to use administrative health data to examine outcomes for individuals with sexually transmitted infections, the ICD-CM-10 codes used to identify persons with chlamydia and gonorrhea have not been validated. Objectives were to determine the validity of using ICD-10-CM codes to identify individuals with chlamydia and gonorrhea. Methods We utilized data from electronic health records gathered from public and private health systems from October 1, 2015 to December 31, 2016. Patients were included if they were aged 13-44 years and received either 1) laboratory testing for chlamydia or gonorrhea or 2) an ICD-10-CM diagnosis of chlamydia, gonorrhea, or an unspecified STI. To validate ICD-10-CM codes, we calculated positive and negative predictive values, sensitivity, and specificity based on the presence of a laboratory test result. We further examined the timing of clinical diagnosis relative to laboratory testing. Results The positive predictive values for chlamydia, gonorrhea, and unspecified STI ICD-10-CM codes were 87.6%, 85.0%, and 32.0%, respectively. Negative predictive values were high (>92%). Sensitivity for chlamydia diagnostic codes was 10.6% and gonorrhea was 9.7%. Specificity was 99.9% for both chlamydia and gonorrhea. The date of diagnosis occurred on or after the date of the laboratory result for 84.8% of persons with chlamydia, 91.9% for gonorrhea, and 23.5% for unspecified STI. Conclusions Disease specific ICD-10-CM codes accurately identify persons with chlamydia and gonorrhea. However, low sensitivities suggest that most individuals could not be identified in administrative data alone without laboratory test results

Leveraging Data Visualization and a Statewide Health Information Exchange to Support COVID-19 Surveillance and Response: Application of Public Health Informatics

Objective We sought to support public health surveillance and response to coronavirus disease 2019 (COVID-19) through rapid development and implementation of novel visualization applications for data amalgamated across sectors. Materials and Methods We developed and implemented population-level dashboards that collate information on individuals tested for and infected with COVID-19, in partnership with state and local public health agencies as well as health systems. The dashboards are deployed on top of a statewide health information exchange. One dashboard enables authorized users working in public health agencies to surveil populations in detail, and a public version provides higher-level situational awareness to inform ongoing pandemic response efforts in communities. Results Both dashboards have proved useful informatics resources. For example, the private dashboard enabled detection of a local community outbreak associated with a meat packing plant. The public dashboard provides recent trend analysis to track disease spread and community-level hospitalizations. Combined, the tools were utilized 133 637 times by 74 317 distinct users between June 21 and August 22, 2020. The tools are frequently cited by journalists and featured on social media. Discussion Capitalizing on a statewide health information exchange, in partnership with health system and public health leaders, Regenstrief biomedical informatics experts rapidly developed and deployed informatics tools to support surveillance and response to COVID-19. Conclusions The application of public health informatics methods and tools in Indiana holds promise for other states and nations. Yet, development of infrastructure and partnerships will require effort and investment after the current pandemic in preparation for the next public health emergency

Spaces of Yoga – Towards a Non-Essentialist Understanding of Yoga

This chapter will examine some of the spaces that yoga occupies in the contemporary world, both physical and social. By looking at yoga through the focus of particular, contested spaces and locations, it will be argued that overarching essentialist definitions of yoga are impossible, although individuals and social groups can and do create essentialist definitions that are more or less useful for particular purposes. By exploring these narratives and boundaries in the context of specific locations, we can better understand what people are doing with the collection of beliefs and practices known as yoga

Early Diagnosis of HIV Infection in Infants - One Caribbean and Six Sub-Saharan African Countries, 2011-2015.

Pediatric human immunodeficiency virus (HIV) infection remains an important public health issue in resource-limited settings. In 2015, 1.4 million children aged 50% decline. The most common challenges for access to testing for early infant diagnosis included difficulties in specimen transport, long turnaround time between specimen collection and receipt of results, and limitations in supply chain management. Further reductions in HIV mortality in children can be achieved through continued expansion and improvement of services for early infant diagnosis in PEPFAR-supported countries, including initiatives targeted to reach HIV-exposed infants, ensure access to programs for early infant diagnosis of HIV, and facilitate prompt linkage to treatment for children diagnosed with HIV infection

Hyperparathyroidism and parathyroidectomy in X-linked hypophosphatemia patients

Background X-linked hypophosphatemia (XLH) causes rickets, osteomalacia, skeletal deformities and growth impairment, due to elevated fibroblast growth factor 23 and hypophosphatemia. Conventional therapy requires high doses of phosphate salts combined with active vitamin D analogues. Risks of this regimen include nephrocalcinosis and secondary hyperparathyroidism or progression to tertiary (hypercalcemic) hyperparathyroidism. Methods The primary goals were to estimate the prevalence of hyperparathyroidism and to characterize parathyroidectomy outcomes regarding hypercalcemia among XLH patients. XLH patients attending our center from 1/2000 to 12/2017 were included in a retrospective chart review. Prevalence of nephrocalcinosis and eGFR<60 mL/min/1.732 was also assessed. Results Of 104 patients with XLH, 84 had concurrent measurements of calcium and PTH (40 adults and 44 children). Of these, 70/84 (83.3%), had secondary or tertiary hyperparathyroidism at any time point. Secondary hyperparathyroidism was persistent in 62.2% of those with data at multiple timepoints. Tertiary hyperparathyroidism had an overall prevalence of 14/84 (16.7%) patients. Parathyroidectomy was performed in 8/84 (9.5%) of the total population. After parathyroidectomy, persistent or recurrent tertiary hyperparathyroidism was detected in 6/8 (75%) patients at a median of 6 years (from 0 to 29 years). One patient had chronic postoperative hypoparathyroidism and one patient remained normocalcemic 4 years after surgery. Nephrocalcinosis was more prevalent in patients with tertiary hyperparathyroidism than those without (60.0% vs 18.6%). Chronic kidney disease (eGFR<60 mL/min/1.732) was also more prevalent in patients with tertiary hyperparathyroidism than those without (35.7% vs 1.5%). Conclusion The majority of patients with XLH develop secondary hyperparathyroidism during treatment with phosphate and active vitamin D. A significant proportion develops tertiary hyperparathyroidism and most have recurrence or persistence of hypercalcemia after surgery

Procalcitonin (PCT)-guided antibiotic stewardship: an international experts consensus on optimized clinical use

Procalcitonin (PCT)-guided antibiotic stewardship (ABS) has been shown to reduce antibiotics (ABxs), with lower side-effects and an improvement in clinical outcomes. The aim of this experts workshop was to derive a PCT algorithm ABS for easier implementation into clinical routine across different clinical settings. Clinical evidence and practical experience with PCT-guided ABS was analyzed and discussed, with a focus on optimal PCT use in the clinical context and increased adherence to PCT protocols. Using a Delphi process, the experts group reached consensus on different PCT algorithms based on clinical severity of the patient and probability of bacterial infection. The group agreed that there is strong evidence that PCT-guided ABS supports individual decisions on initiation and duration of ABx treatment in patients with acute respiratory infections and sepsis from any source, thereby reducing overall ABx exposure and associated side effects, and improving clinical outcomes. To simplify practical application, the expert group refined the established PCT algorithms by incorporating severity of illness and probability of bacterial infection and reducing the fixed cut-offs to only one for mild to moderate and one for severe disease (0.25 μg/L and 0.5 μg/L, respectively). Further, guidance on interpretation of PCT results to initiate, withhold or discontinue ABx treatment was included. A combination of clinical patient assessment with PCT levels in well-defined ABS algorithms, in context with continuous education and regular feedback to all ABS stakeholders, has the potential to improve the diagnostic and therapeutic management of patients suspected of bacterial infection, thereby improving ABS effectiveness.</p