Research and applications: ICD-9 tobacco use codes are effective identifiers of smoking status

Objective

To evaluate the validity of, characterize the usage of, and propose potential research applications for International Classification of Diseases, Ninth Revision (ICD-9) tobacco codes in clinical populations.

Materials and methods

Using data on cancer cases and cancer-free controls from Vanderbilt''s biorepository, BioVU, we evaluated the utility of ICD-9 tobacco use codes to identify ever-smokers in general and high smoking prevalence (lung cancer) clinic populations. We assessed potential biases in documentation, and performed temporal analysis relating transitions between smoking codes to smoking cessation attempts. We also examined the suitability of these codes for use in genetic association analyses.

Results

ICD-9 tobacco use codes can identify smokers in a general clinic population (specificity of 1, sensitivity of  0.32), and there is little evidence of documentation bias. Frequency of code transitions between ‘current’ and ‘former’ tobacco use was significantly correlated with initial success at smoking cessation (p<0.0001). Finally, code-based smoking status assignment is a comparable covariate to text-based smoking status for genetic association studies.

Discussion

Our results support the use of ICD-9 tobacco use codes for identifying smokers in a clinical population. Furthermore, with some limitations, these codes are suitable for adjustment of smoking status in genetic studies utilizing electronic health records.

Conclusions

Researchers should not be deterred by the unavailability of full-text records to determine smoking status if they have ICD-9 code histories.     

Diagnosis of Mycobacterium tuberculosis using molecular biology technology

Objective

To present an integrated molecular biology dedicated system for tuberculosis diagnosis.

Methods

One hundred and five sputum specimens from patients strongly suspected by clinical parameters of tuberculosis were studied by Ziehl-Neelsen staining, by cultivation on solid medium and by a balanced heminested fluorometric PCR system (Orange G3TB) that could preserve worker safety and produce a rather pure material free of potential inhibitors. DNA amplification was performed in a low cost tuberculosis termocycler-fluorometer. Produced double stranded DNA was flurometrically detected. The whole reaction was conducted in one single tube which would not be opened after adding the processed sample in order to minimize the risk of cross contamination with amplicons.

Results

The assay was able to detect 30 bacillus per sample mL with 99.8% interassay variation coefficient. PCR was positive in 23 (21.9%) tested samples (21 of them were smear negative). In our study it showed a preliminary sensitivity of 94.5% for sputum and an overall specificity of 98.7%.

Conclusions

Total run time of the test is 4 h with 2.5 real working time. All PCR positive samples are also positive by microbiological culture and clinical criteria. Results show that it could be a very useful tool to increase detection efficiency of tuberculosis disease in low bacilus load samples. Furthermore, its low cost and friendly using make it feasible to run in poor regions.     

Spectrum of Childhood Tuberculosis in BCG Vaccinated and Unvaccinated Children

Background

Childhood tuberculosis remains a major public health problem in India. We evaluated the impact of BCG vaccination on childhood tuberculosis and the underlying risk factors.

Methods

100 consecutive children below 12 years diagnosed to have tuberculosis based on the WHO and IAP consensus statement were included in the study.

Result

Majority(42%) of children with tuberculosis were below four years of age. History of contact with a case of tuberculosis was present in 41 cases. BCG scar was present in 77 cases indicating a poor coverage/uptake of BCG vaccination. Pulmonary form of tuberculosis was seen in 52 and extra pulmonary form in 41 cases. Tubercular lymphadenitis was seen in seven cases, of which more than 70 % were in BCG vaccinated group. There was no statistically significant difference in the type of tuberculosis (pulmonary or extra pulmonary) and BCG vaccination. In the extra pulmonary form, 13 children had neuro-tuberculosis, of which 66% were in BCG unvaccinated group, which was statistically significant (p=0.011). The underlying risk factors were poor socioeconomic status (62%), malnutrition (61%) and poor immunization coverage.

Conclusion

Higher incidence of pulmonary tuberculosis in BCG vaccinated group was not statistically significant. However, high incidence of neuro-tuberculosis in BCG unvaccinated group was statistically significant. The underlying risk factors were poor socio-economic status, malnutrition and poor immunization coverage and should be taken into consideration in order to prevent morbidity and mortality due to tuberculosis in children.Key Words: Bacille Calmette Guerin vaccine, Tuberculosis     

Time of foaling in Arabian mares raised in Tiaret,Algeria

Objective

To enhance effectiveness of reproduction management in Arabian mares, factors influencing the time of foaling were investigated in this study.

Methods

Data were collected at the National Haras of Tiaret in Algeria from 2003 to 2010. The foaling time of 255 Arabian pure bred mares, aged from 3 to 20 years were used for this study.

Results

A total of 78.07% of foaling happens between 7 pm and 6 am.

Conclusions

The influence of the month of foaling and the sex of the foal, on the time of foaling was statically significant.     

The impact of electronic medical records data sources on an adverse drug event quality measure

Objective

To examine the impact of billing and clinical data extracted from an electronic medical record system on the calculation of an adverse drug event (ADE) quality measure approved for use in The Joint Commission''s ORYX program, a mandatory national hospital quality reporting system.

Design

The Child Health Corporation of America''s “Use of Rescue Agents—ADE Trigger” quality measure uses medication billing data contained in the Pediatric Health Information Systems (PHIS) data warehouse to create The Joint Commission-approved quality measure. Using a similar query, we calculated the quality measure using PHIS plus four data sources extracted from our electronic medical record (EMR) system: medications charged, medication orders placed, medication orders with associated charges (orders charged), and medications administered.

Measurements

Inclusion and exclusion criteria were identical for all queries. Denominators and numerators were calculated using the five data sets. The reported quality measure is the ADE rate (numerator/denominator).

Results

Significant differences in denominators, numerators, and rates were calculated from different data sources within a single institution''s EMR. Differences were due to both common clinical practices that may be similar across institutions and unique workflow practices not likely to be present at any other institution. The magnitude of the differences would significantly alter the national comparative ranking of our institution compared to other PHIS institutions.

Conclusions

More detailed clinical information may result in quality measures that are not comparable across institutions due institution-specific workflow, differences that are exposed using EMR-derived data.     

Comparative Evaluation of Ziehl Neelsen Staining and Knowledge,Attitudes and Practices of Laboratory Personnel in Relation to Ziehl Nielsen

Objective:

To describe laboratory personnel''s attitude and practices toward phenol exposure during Ziehl Neelsen (ZN) acid fast staining method and to evaluate the feasibility of an alternate modified Kinyoun cold (MKC) stain.

Method:

A total of 187 sputum samples were collected from suspected tuberculosis cases and stained by the MKC method and ZN stain and were read by an experienced microscopist and a researcher. A cross-sectional questionnaire survey of 35 laboratory personnel was also conducted.

Results:

Modified Kinyoun cold stain gave sensitivity, specificity, positive and negative predictive values of 100%, 99.4%, 94.1% and 100%, respectively. Both stains corresponded with an agreement rate of 99.5%. Almost 94.7% of respondents reported that they worked in a closed area when staining and 57.1% did the staining method without ventilation. Material safety data sheet (MSDS) of phenol was not known to 77.1% of laboratory personnel. All of the participants (100%) in this study welcomed a similar, non heating method for acid-fast bacillus (AFB). There was significant association between those not comfortable with phenol exposure (77.1%) and complaints of irritation (48.6%) and headache (2.9%) [χ² = 10.98, r = 0.55, p = 0.001].

Conclusions:

The MKC is suitable for use as a substitute for the ZN method for the demonstration of AFB in the primary diagnosis and treatment assessment of pulmonary tuberculosis. Focus should be given on educating laboratory staff on the hazards, risks and precautions associated with the phenol/ZN method.     

Genetic data and electronic health records: a discussion of ethical,logistical and technological considerations

Objective

The completion of sequencing the human genome in 2003 has spurred the production and collection of genetic data at ever increasing rates. Genetic data obtained for clinical purposes, as is true for all results of clinical tests, are expected to be included in patients’ medical records. With this explosion of information, questions of what, when, where and how to incorporate genetic data into electronic health records (EHRs) have reached a critical point. In order to answer these questions fully, this paper addresses the ethical, logistical and technological issues involved in incorporating these data into EHRs.

Materials and methods

This paper reviews journal articles, government documents and websites relevant to the ethics, genetics and informatics domains as they pertain to EHRs.

Results and discussion

The authors explore concerns and tasks facing health information technology (HIT) developers at the intersection of ethics, genetics, and technology as applied to EHR development.

Conclusions

By ensuring the efficient and effective incorporation of genetic data into EHRs, HIT developers will play a key role in facilitating the delivery of personalized medicine.     

A Framework for evaluating the costs, effort, and value of nationwide health information exchange

Objective

The nationwide health information network (NHIN) has been proposed to securely link community and state health information exchange (HIE) entities to create a national, interoperable network for sharing healthcare data in the USA. This paper describes a framework for evaluating the costs, effort, and value of nationwide data exchange as the NHIN moves toward a production state. The paper further presents the results of an initial assessment of the framework by those engaged in HIE activities.

Design

Using a literature review and knowledge gained from active NHIN technology and policy development, the authors constructed a framework for evaluating the costs, effort, and value of data exchange between an HIE entity and the NHIN.

Measurement

An online survey was used to assess the perceived usefulness of the metrics in the framework among HIE professionals and researchers.

Results

The framework is organized into five broad categories: implementation; technology; policy; data; and value. Each category enumerates a variety of measures and measure types. Survey respondents generally indicated the framework contained useful measures for current and future use in HIE and NHIN evaluation. Answers varied slightly based on a respondent''s participation in active development of NHIN components.

Conclusion

The proposed framework supports efforts to measure the costs, effort, and value associated with nationwide data exchange. Collecting longitudinal data along the NHIN''s path to production should help with the development of an evidence base that will drive adoption, create value, and stimulate further investment in nationwide data exchange.     

Research and applications: Role of genetic heterogeneity and epistasis in bladder cancer susceptibility and outcome: a learning classifier system approach

Background and objective

Detecting complex patterns of association between genetic or environmental risk factors and disease risk has become an important target for epidemiological research. In particular, strategies that provide multifactor interactions or heterogeneous patterns of association can offer new insights into association studies for which traditional analytic tools have had limited success.

Materials and methods

To concurrently examine these phenomena, previous work has successfully considered the application of learning classifier systems (LCSs), a flexible class of evolutionary algorithms that distributes learned associations over a population of rules. Subsequent work dealt with the inherent problems of knowledge discovery and interpretation within these algorithms, allowing for the characterization of heterogeneous patterns of association. Whereas these previous advancements were evaluated using complex simulation studies, this study applied these collective works to a ‘real-world’ genetic epidemiology study of bladder cancer susceptibility.

Results and discussion

We replicated the identification of previously characterized factors that modify bladder cancer risk—namely, single nucleotide polymorphisms from a DNA repair gene, and smoking. Furthermore, we identified potentially heterogeneous groups of subjects characterized by distinct patterns of association. Cox proportional hazard models comparing clinical outcome variables between the cases of the two largest groups yielded a significant, meaningful difference in survival time in years (survivorship). A marginally significant difference in recurrence time was also noted. These results support the hypothesis that an LCS approach can offer greater insight into complex patterns of association.

Conclusions

This methodology appears to be well suited to the dissection of disease heterogeneity, a key component in the advancement of personalized medicine.     

Identification of biomarkers for hepatocellular carcinoma using network-based bioinformatics methods

Background

Hepatocellular carcinoma (HCC) is one of the most common types of cancer worldwide. Despite several efforts to elucidate molecular mechanisms involved in this cancer, they are still not fully understood.

Methods

To acquire further insights into the molecular mechanisms of HCC, and to identify biomarkers for early diagnosis of HCC, we downloaded the gene expression profile on HCC with non-cancerous liver controls from the Gene Expression Omnibus (GEO) and analyzed these data using a combined bioinformatics approach.

Results

The dysregulated pathways and protein-protein interaction (PPI) network, including hub nodes that distinguished HCCs from non-cancerous liver controls, were identified. In total, 29 phenotype-related differentially expressed genes were included in the PPI network. Hierarchical clustering showed that the gene expression profile of these 29 genes was able to differentiate HCC samples from non-cancerous liver samples. Among these genes, CDC2 (Cell division control protein 2 homolog), MMP2 (matrix metalloproteinase-2) and DCN (Decorin were the hub nodes in the PPI network.

Conclusions

This study provides a portfolio of targets useful for future investigation. However, experimental studies should be conducted to verify our findings.     

Use of Otoacoustic Emissions (OAE) to detect sub-clinical inner ear damage in divers of the Indian Navy

Background

Professional Divers are at a high risk of Sensorineural Hearing Impairment. Divers may sustain sub-clinical hearing loss that is not identified on pure tone audiometry (PTA). Otoacoustic Emissions (OAE) reflect the functional status of the Outer Hair Cells. OAE testing constitutes the only non-invasive means of objective cochlear investigation and may be a more sensitive measure than PTA in identifying sub-clinical hearing loss.

Methods

This cross-sectional study was performed to determine utility of Otoacoustic Emissions testing in detecting sub-clinical Inner Ear damage in divers of Indian Navy. Transient Evoked Otoacoustic Emissions (TEOAE) levels were measured in 50 audiologically asymptomatic ship divers of Indian Navy and compared with control group comprising of 50 normal hearing individuals.

Results

No statistically significant differences were observed between the study and control group. Also no correlation was observed between diving years and TEOAE levels. There was no correlation greater than −0.49 between diving years and TEOAE SNR.

Conclusions

We concluded that TEOAE levels are not a sensitive tool in identifying ships divers without any history of noise exposure at risk for developing hearing loss.     

Impact of gastro-oesophageal reflux disease on work productivity despite therapy with proton pump inhibitors in Germany

Background

Gastro-oesophageal reflux disease (GERD) is a common disorder with consequences for the patient''s health-related quality of life (HRQoL). In Germany, few data are available on the impact of GERD on work-related productivity.

Aim

To study the impact of GERD on work productivity despite proton pump inhibitor (PPI) therapy and the association between productivity and symptom duration, severity, and HRQoL.

Methods

Retrospective data from randomly selected patients with chronic GERD symptoms, treated by office-based general practitioners or general internists with routine clinical care, were analyzed together with information from self-administered instruments assessing work productivity (WPAI-GERD), symptoms (RDQ), and HRQoL (QOLRAD).

Results

Reduced productivity was reported by 152 of 249 patients (61.0%), although 89.5% of them were treated with PPI. The reduction in work productivity was 18.5% in all patients and 30.3% in those with reduced productivity. Patients with impaired productivity showed a significantly lower HRQoL and more-severe symptoms of reflux disease. In all patients, the mean sick leave attributable to reflux symptoms was 0.6 hours in the previous seven days and 1.4 work days in the previous three months.

Conclusion

GERD has a substantial impact on work productivity in Germany, even in patients receiving routine clinical care and PPI therapy.     

From web search to healthcare utilization: privacy-sensitive studies from mobile data

Objective

We explore relationships between health information seeking activities and engagement with healthcare professionals via a privacy-sensitive analysis of geo-tagged data from mobile devices.

Materials and methods

We analyze logs of mobile interaction data stripped of individually identifiable information and location data. The data analyzed consist of time-stamped search queries and distances to medical care centers. We examine search activity that precedes the observation of salient evidence of healthcare utilization (EHU) (ie, data suggesting that the searcher is using healthcare resources), in our case taken as queries occurring at or near medical facilities.

Results

We show that the time between symptom searches and observation of salient evidence of seeking healthcare utilization depends on the acuity of symptoms. We construct statistical models that make predictions of forthcoming EHU based on observations about the current search session, prior medical search activities, and prior EHU. The predictive accuracy of the models varies (65%–90%) depending on the features used and the timeframe of the analysis, which we explore via a sensitivity analysis.

Discussion

We provide a privacy-sensitive analysis that can be used to generate insights about the pursuit of health information and healthcare. The findings demonstrate how large-scale studies of mobile devices can provide insights on how concerns about symptomatology lead to the pursuit of professional care.

Conclusion

We present new methods for the analysis of mobile logs and describe a study that provides evidence about how people transition from mobile searches on symptoms and diseases to the pursuit of healthcare in the world.     

Extrapulmonary Tuberculosis in Human Immunodificiency Virus Infection

Background

In view of increase in incidence of exptrapulmonary tuberculosis after the epidemic of human immunodeficiency virus infection, the clinical profile of extrapulmonary tuberculosis in patients with HIV infection was studied.

Method

The study population comprised patients of HIV infection with extrapulmonary tuberculosis. Work up included history, clinical examination, sputum for acid fast bacilli, chext X-ray, ultrasonography (USG) abdomen, fine needle aspiration cytology(FNAC), transbronchial needle aspiration (TBNA) and computed tomography of chest.

Results

There were 50 cases, all males with mean age of 35 years. 24(48%) were without pulmonary tuberculosis and 26(52%) had pulmonary tuberculosis. 41(82%) had disseminated disease and 9(18%) involve one site. Fever and weight loss were the most frequent symptoms (79% and 58% respectively) in cases without pulmonary tuberculosis. The most frequent extrapulmonary site was lymph node in 46(92%), followed by spleen in 13(26%), pleura 9(18%), miliary 7(14%) and hepatic 1(2%). The diagnosis was confirmed by invasive methods in 30 out of 50(60%) cases [FNAC in 23(88%), TBNA in 2(25%) and pleural biopsy in 5(55%)].

Conclusion

In HIV infected patients, the most common extrapulmonary site is lymph mode followed by spleen.Key Words: Extrapulmonary TB, HIV Infection     

Study of blood pressure profile of school children 6–15 years in a rural setting of Maharashtra

Background

High blood pressure in childhood is a major risk factor for heart disease and stroke in adulthood. There is enough evidence to suggest that the roots of essential hypertension in adults extend into childhood. There is a paucity of literature on the blood pressure measurements amongst children. This study was done to study blood pressure profile of school children in rural area of Maharashtra.

Aim & objectives

This cross sectional study was carried out to determine the prevalence of hypertension in children 6–15 years and to study the association between selected variables and blood pressure.

Material & methods

This study was done using a predesigned questionnaire and making measurements of height, BMI and Blood pressure using standardized physical instruments following standard guidelines. The data was collected and analyzed using appropriate statistical tests.

Results

The prevalence of hypertension in the study was found to be 4.4% with 3.5% in females and 5.1% in males.

Conclusion

In the study, hypertension in students was found to be significantly associated with higher BMI and with family history of hypertension. Age, height and BMI were found to correlate positively with Blood pressure levels in this study.     

The feasibility of automating audit and feedback for ART guideline adherence in Malawi

Objective

To determine the feasibility of using electronic medical record (EMR) data to provide audit and feedback of antiretroviral therapy (ART) clinical guideline adherence to healthcare workers (HCWs) in Malawi.

Materials and methods

We evaluated recommendations from Malawi''s ART guidelines using GuideLine Implementability Appraisal criteria. Recommendations that passed selected criteria were converted into ratio-based performance measures. We queried representative EMR data to determine the feasibility of generating feedback for each performance measure, summed clinical encounters representing each performance measure''s denominator, and then measured the distribution of encounter frequency for individual HCWs across nurse and clinical officer groups.

Results

We analyzed 423 831 encounters in the EMR data and generated automated feedback for 21 recommendations (12%) from Malawi''s ART guidelines. We identified 11 nurse recommendations and eight clinical officer recommendations. Individual nurses and clinical officers had an average of 45 and 59 encounters per month, per recommendation, respectively. Another 37 recommendations (21%) would support audit and feedback if additional routine EMR data are captured and temporal constraints are modeled.

Discussion

It appears feasible to implement automated guideline adherence feedback that could potentially improve HCW performance and supervision. Feedback reports may support workplace learning by increasing HCWs'' opportunities to reflect on their performance.

Conclusion

A moderate number of recommendations from Malawi''s ART guidelines can be used to generate automated guideline adherence feedback using existing EMR data. Further study is needed to determine the receptivity of HCWs to peer comparison feedback and barriers to implementation of automated audit and feedback in low-resource settings.     

Can poison control data be used for pharmaceutical poisoning surveillance?

Objective

To determine the association between the frequencies of pharmaceutical exposures reported to a poison control center (PCC) and those seen in the emergency department (ED).

Design

A statewide population-based retrospective comparison of frequencies of ED pharmaceutical poisonings with frequencies of pharmaceutical exposures reported to a regional PCC. ED poisonings, identified by International Classification of Diseases, Version 9 (ICD-9) codes, were grouped into substance categories. Using a reproducible algorithm facilitated by probabilistic linkage, codes from the PCC classification system were mapped into the same categories. A readily identifiable subset of PCC calls was selected for comparison.

Measurements

Correlations between frequencies of quarterly exposures by substance categories were calculated using Pearson correlation coefficients and partial correlation coefficients with adjustment for seasonality.

Results

PCC reported exposures correlated with ED poisonings in nine of 10 categories. Partial correlation coefficients (r_p) indicated strong associations (r_p>0.8) for three substance categories that underwent large changes in their incidences (opiates, benzodiazepines, and muscle relaxants). Six substance categories were moderately correlated (r_p>0.6). One category, salicylates, showed no association.

Limitations

Imperfect overlap between ICD-9 and PCC codes may have led to miscategorization. Substances without changes in exposure frequency have inadequate variability to detect association using this method.

Conclusion

PCC data are able to effectively identify trends in poisonings seen in EDs and may be useful as part of a pharmaceutical poisoning surveillance system. The authors developed an algorithm-driven technique for mapping American Association of Poison Control Centers codes to ICD-9 codes and identified a useful subset of poison control exposures for analysis.