Assessing the accuracy of electronic health record gender identity and REaL data at an academic medical center.

BACKGROUND: Collection of accurate patient race, ethnicity, preferred language (REaL) and gender identity in the electronic health record (EHR) is essential for equitable and inclusive care. Misidentification of these factors limits quality measurement of health outcomes in at-risk populations. Therefore, the aim of our study was to assess the accuracy of REaL and gender identity data at our institution. METHODS: A survey was administered to 117 random patients, selected from prior day admissions at a large academic medical center in urban central New York. Patients (or guardians) self-reported REaL and gender identity data, selecting from current EHR options. Variables were coded for the presence or absence of a difference from data recorded in the EHR. RESULTS: Race was misreported in the EHR for 13% of patients and ethnicity for 6%. For most White and Black patients, race was concordant. However, self-identified data for all multiracial patients were discordant with the EHR. Most Non-Hispanic patients had ethnicity correctly documented. Some Hispanic patients were misidentified. There was a significant association between reporting both a race and an ethnicity which differed from the EHR on chi square analysis (P < 0.001). Of those who reported an alternative ethnicity, 71.4% also reported an alternative race. Gender identity was missing for most patients and 11% of the gender-identity entries present in the EHR were discordant with the patient's self-identity. Preferred language was 100% concordant with the EHR. CONCLUSIONS: At an academic medical center, multiracial and Hispanic patients were more likely to have their demographics misreported in the EHR, and gender identity data were largely missing. Healthcare systems need strategies that support accurate collection of patients' self-reported ReAL and gender identity data to improve the future ability to identify and address healthcare disparities.

A retrospective chart review of trauma-related documentation in an Australian substance use treatment service.

INTRODUCTION: Trauma exposure among clients of substance use treatment services is almost universal and rates of trauma-related symptoms are correspondingly high. This study examined one aspect of clinical care-clinical documentation-and sought to systematically assess the documentation of trauma-related comorbidities and their treatment in a substance use treatment setting. METHODS: A retrospective chart review was conducted on a sample of 300 patient records in a public substance use treatment setting. Rates of documentation of trauma-related events, symptoms and treatment, along with variables influencing the documentation of these issues, were examined. RESULTS: Trauma-related documentation was present in 45.3% of records. There were documented trauma-related symptoms in 15.3% of records, although treatment activities addressing trauma were only present in 2.3% of records. Being female (odds ratio [OR] 2.58, 95% confidence interval [CI] 1.42, 4.69), having prior mental health treatment (OR 1.82, 95% CI 1.05, 1.12) and having more treatment sessions (OR 1.08, 95% CI = 1.05, 1.12) increased the odds of trauma-related documentation being present, while being in the first episode of treatment (OR 0.49, 95% CI = 0.28, 0.84) decreased the odds. DISCUSSION AND CONCLUSIONS: This study highlights significant under documentation of trauma-related comorbidities in substance-use treatment. There is limited evidence of consideration of trauma-related symptoms or diagnoses, and trauma-related comorbidities are rarely included in treatment planning activities. The lack of documented trauma-related information has important clinical and medico-legal implications for patients, and provides evidence to suggest a lack of integration of treatment for trauma-related disorders in substance use settings.

Insulin edema after initiation of hybrid closed-loop insulin pump therapy with continuous glucose monitoring: a case report.

BACKGROUND: Insulin edema is a rare complication which can present after initiation or intensification of insulin therapy in people with diabetes. Initiation of closed-loop hybrid insulin pump therapy can result in rapid improvement in glycemic control for people with diabetes. We present a case in which transition to a closed-loop hybrid insulin pump system, followed by significant improvement in glycemic control, led to development of insulin edema in a person with type 1 diabetes. CASE PRESENTATION: We present a 51-year-old woman with type 1 diabetes of 16 years duration, on insulin pump therapy for more than 10 years, who presented for follow-up 7 weeks after transitioning to a hybrid closed-loop insulin pump system with continuous glucose monitoring (CGM). She complained of weight gain and bilateral lower extremity edema which had started two weeks after the change in pump modality. Laboratory studies and echocardiogram did not reveal any etiology of the acute edema. HbA1c was 3.3% lower than the previous measurement 15 weeks earlier, and there was a significant increase in the daily total insulin dose. With exclusion of other causes of acute edema, the patient was diagnosed with insulin edema and started on hydrochlorothiazide. On follow up, her lower extremity edema significantly improved although her weight did not return to baseline. CONCLUSION: To our knowledge, this is the first case of insulin edema reported in a person with type 1 diabetes using CGM and a hybrid closed-loop insulin pump system. The increase in total daily insulin dose, rapid improvement of glycemic control, and lack of hypoglycemic episodes were important factors to consider in evaluation of this case. Use of hybrid closed-loop systems can help achieve rapid improvement in glycemic control in people with diabetes. This case suggests that consideration should be given to adjusting initial blood glucose targets when starting these remarkable new technologies in people with baseline poor glycemic control.

Neanderthals on the Lower Danube: Middle Palaeolithic evidence in the Danube Gorges of the Balkans.

The article presents evidence about the Middle Palaeolithic and Middle to Upper Palaeolithic transition interval in the karst area of the Danube Gorges in the Lower Danube Basin. We review the extant data and present new evidence from two recently investigated sites found on the Serbian side of the Danube River - Tabula Traiana and Dubocka-Kozja caves. The two sites have yielded layers dating to both the Middle and Upper Palaeolithic and have been investigated by the application of modern standards of excavation and recovery along with a suite of state-of-the-art analytical procedures. The presentation focuses on micromorphological analyses of the caves' sediments, characterisation of cryptotephra, a suite of new radiometric dates (accelerator mass spectrometry and optically stimulated luminescence) as well as proteomics (zooarchaeology by mass spectrometry) and stable isotope data in discerning patterns of human occupation of these locales over the long term.

Implicit Racial-Ethnic and Insurance-Mediated Bias to Recommending Diabetes Technology: Insights from T1D Exchange Multicenter Pediatric and Adult Diabetes Provider Cohort.

Background: Despite documented benefits of diabetes technology in managing type 1 diabetes, inequities persist in the use of these devices. Provider bias may be a driver of inequities, but the evidence is limited. Therefore, we aimed to examine the role of race/ethnicity and insurance-mediated provider implicit bias in recommending diabetes technology. Method: We recruited 109 adult and pediatric diabetes providers across 7 U.S. endocrinology centers to complete an implicit bias assessment composed of a clinical vignette and ranking exercise. Providers were randomized to receive clinical vignettes with differing insurance and patient names as proxy for Racial-Ethnic identity. Bias was identified if providers: (1) recommended more technology for patients with an English name (Racial-Ethnic bias) or private insurance (insurance bias), or (2) Race/Ethnicity or insurance was ranked high (Racial-Ethnic and insurance bias, respectively) in recommending diabetes technology. Provider characteristics were analyzed using descriptive statistics and multivariate logistic regression. Result: Insurance-mediated implicit bias was common in our cohort (n = 66, 61%). Providers who were identified to have insurance-mediated bias had greater years in practice (5.3 ± 5.3 years vs. 9.3 ± 9 years, P = 0.006). Racial-Ethnic-mediated implicit bias was also observed in our study (n = 37, 34%). Compared with those without Racial-Ethnic bias, providers with Racial-Ethnic bias were more likely to state that they could recognize their own implicit bias (89% vs. 61%, P = 0.001). Conclusion: Provider implicit bias to recommend diabetes technology was observed based on insurance and Race/Ethnicity in our pediatric and adult diabetes provider cohort. These data raise the need to address provider implicit bias in diabetes care.

Proteome Variation with Collagen Yield in Ancient Bone.

Isotope analyses are some of the most common analytical methods applied to ancient bone, aiding the interpretation of past diets and chronology. For this, the evaluation of "collagen yield" (as defined in radiocarbon dating and stable isotope research) is a routine step that allows for the selection of specimens that are deemed adequate for subsequent analyses, with samples containing less than ∼1% "collagen yield" normally being used for isotopic analysis but discounted for radiocarbon dating. The aims of this study were to use proteomic methods of MALDI-TOF (matrix assisted laser desorption ionization time-of-fligh mass spectrometry) and LC-ESI-MS/MS (liquid chromatography electrospray ionization tandem mass spectrometry) to investigate the endogeneity of the dominant proteinaceous biomolecules within samples that are typically considered to contain poorly preserved protein. Taking 29 archaeological samples, we evaluated the proteome variability between different acid-soluble fractions removed prior to protein gelatinization and considered waste as part of the radiocarbon dating process. We then correlated these proteomes against the commonly used "collagen yield" proxy for preservation. We found that these waste fractions contained a significant amount of both collagenous and noncollagenous proteins (NCPs) but that the abundance of these was not correlated with the acquired "collagen yield". Rather than a depleted protein load as would be expected from a low "collagen yield", the variety of the extracted NCPs was comparable with that commonly obtained from ancient samples and included informative proteins useful for species identification, phylogenetic studies, and potentially even for isotopic analyses, given further method developments. Additionally, we did not observe any correlation between "collagen yield" and peptide mass fingerprint success or between the different fractions taken from the same sample but at different radiocarbon pretreatment stages. Overall, these findings highlight the value in retaining and analyzing sample fractions that are otherwise discarded as waste during the radiocarbon dating process but more importantly, that low "collagen yield" specimens that are often misinterpreted by archaeologists as being devoid of protein can still yield useful molecular sequence-based information.

Insulin Edema With Use of U-500 Regular Insulin in a Hybrid Closed-Loop Insulin Pump.

Insulin edema is a rare complication of insulin therapy which has been described in known or newly diagnosed people with diabetes, following initiation or intensification of insulin treatment. Here we present a 63-year-old man with complaints of weight gain, shortness of breath, and lower extremity edema starting two weeks after the change of his insulin pump to the hybrid closed-loop insulin pump system and substitution of U-100 aspart insulin with U-500 regular insulin. Laboratory studies, imaging, and electrocardiogram (EKG) were performed to evaluate the cause of acute edema and were all normal. Hemoglobin A1C showed remarkable improvement after the pump change and the insulin pump download showed a significant increase in the amount of total daily insulin administered. With the exclusion of other causes of acute edema, the patient was diagnosed with insulin edema. He was started on spironolactone 50 mg/daily and showed a desirable improvement of edema on follow-up.  This case shows that although the use of the hybrid insulin-pump system helps to obtain better control of diabetes in many patients, the rapid improvement in glycemic control may precipitate the development of insulin edema. Furthermore, the use of high concentration insulin in insulin pumps is off-label and their use might increase the rate of complications of insulin therapy including insulin edema.

Origins and genetic legacies of the Caribbean Taino.

The Caribbean was one of the last parts of the Americas to be settled by humans, but how and when the islands were first occupied remains a matter of debate. Ancient DNA can help answering these questions, but the work has been hampered by poor DNA preservation. We report the genome sequence of a 1,000-year-old Lucayan Taino individual recovered from the site of Preacher's Cave in the Bahamas. We sequenced her genome to 12.4-fold coverage and show that she is genetically most closely related to present-day Arawakan speakers from northern South America, suggesting that the ancestors of the Lucayans originated there. Further, we find no evidence for recent inbreeding or isolation in the ancient genome, suggesting that the Lucayans had a relatively large effective population size. Finally, we show that the native American components in some present-day Caribbean genomes are closely related to the ancient Taino, demonstrating an element of continuity between precontact populations and present-day Latino populations in the Caribbean.

Placebo effects in hearing-aid trials are reliable.

OBJECTIVE: A recent study suggested that placebo effects are a source of bias in non-blinded hearing-aid trials. Given the potential impact of this finding on the interpretation of non-blinded trials and design of future research trials, the objective of the present study was to investigate the reliability of this effect. DESIGN: Using the same procedure as an earlier study, participants were told that they were taking part in a trial of new hearing-aid technology. Participants compared two devices that were acoustically identical, except one was described as "new" and the other as "conventional". Participants completed a speech-in-noise test, sound quality ratings, and rated overall personal preference for both hearing aids. STUDY SAMPLE: Sixteen adult hearing-aid users. RESULTS: Participants had significantly better mean speech-in-noise performance (70.9% versus 66.8%, Z = 2.30, p = 0.02, effect size Pearson's r = 0.15) and sound quality ratings for the "new" hearing aid (8.1 versus 7.4, Z = - 2.99, p = 0.003, r = 0.28). A significant proportion of participants (75%) expressed an overall preference for the "new" hearing aid (p = 0.001, effect size φc = 0.66). CONCLUSION: Placebo effects reliably impact on hearing-aid trials. In order to control for placebo effects, double-blind methodology is optimal. However, when double-blinding is not possible other strategies may be appropriate.

Feasibility of immediate assessment of fine needle aspirates of thyroid nodules by telecytopathology.

OBJECTIVE: In this study we discuss the diagnostic accuracy and unsatisfactory rate of onsite evaluation of ultrasound-guided fine needle aspiration (USGFNA) of thyroid nodules using telecytopathology and compare it to that of a control group without telecytopathology. METHODS: This was a retrospective analysis of USGFNA of thyroid nodules over a 9-month period with and without telecytopathology. There was no randomization for selection of the groups with and without telepathologist. A single provider performed all the procedures. Real-time images of Diff Quik-stained cytology smears were obtained with an Olympus Digital camera attached to an Olympus CX41 microscope and transmitted via the Internet by a cytotechnologist to a pathologist, who communicated the preliminary diagnosis and sample adequacy. The unsatisfactory specimen rate was compared between a group whose images were transmitted (n = 45) and another group without onsite adequacy assessment (nontransmitted) (n = 47). RESULTS: A total of 92 nodules in 67 patients were aspirated with ultrasound guidance. The unsatisfactory sample rate in the transmitted group was 13% (6 out of 45) and that of the non-transmitted group was 23% (11 out of 47). In the transmitted group, the cytology specimens of 3 patients that were initially deemed inadequate by the pathologist were considered adequate after 2 additional passes. In the transmitted group, preliminary diagnosis concurred with the final diagnosis in 96% of cases. Four passes were made in the non-transmitted group, versus 2 passes in the transmitted group. CONCLUSION: Immediate assessment of USGFNA via telecytopathology assures adequacy of the cytology sample and may reduce number of passes per nodule. Preliminary onsite telecytopathology diagnosis was highly accurate when compared to final diagnosis.

Development and treatment of tertiary hyperparathyroidism in patients with pseudohypoparathyroidism type 1B.

CONTEXT: Pseudohypoparathyroidism type 1B (PHP1B) patients have PTH resistance at the renal proximal tubule and develop hypocalcemia and secondary hyperparathyroidism. Hyperparathyroid bone disease also develops in some patients. PHP1B patients are at theoretical risk of developing tertiary hyperparathyroidism. SETTING: Patients were studied in a clinical research center. PATIENTS: Five female PHP1B patients presented with hypercalcemia and elevated PTH. INTERVENTION: Patients either underwent parathyroidectomy (n = 4) or received cinacalcet (n = 1). MAIN OUTCOME MEASURES: Serum calcium and PTH were serially measured before and after intervention. RESULTS: Five PHP1B patients developed concomitantly elevated serum calcium and PTH levels (range, 235-864 ng/liter) requiring termination of calcium and vitamin D therapy (time after diagnosis, 21-42 yr; median, 34 yr), consistent with tertiary hyperparathyroidism. Four patients underwent parathyroidectomy with removal of one (n = 2) or two (n = 2) enlarged parathyroid glands. Calcium and vitamin D therapy was reinstituted postoperatively, and at 93-month median follow-up, PTH levels ranged between 56 and 182 (normal, <87) ng/liter. One patient was treated with cinacalcet, resulting in resolution of hypercalcemia. CONCLUSIONS: PHP1B patients are at risk of developing tertiary hyperparathyroidism and/or hyperparathyroid bone disease and should therefore be treated with sufficient doses of calcium and vitamin D to achieve serum calcium and PTH levels within or as close to the normal range as possible. Surgery is the treatment of choice in this setting. Cinacalcet may be a useful alternative in those who do not undergo surgery.

Acetylation of nuclear hormone receptor superfamily members: thyroid hormone causes acetylation of its own receptor by a mitogen-activated protein kinase-dependent mechanism.

Because the androgen and estrogen nuclear hormone receptors are subject to acetylation, we speculated that the nuclear thyroid hormone receptor-beta1 (TRbeta1), another superfamily member, was also subject to this posttranslational modification. Treatment of 293T cells that contain TRbeta1(wt) with l-thyroxine (T4)(10(-7)M, total concentration) resulted in the accumulation of acetylated TR in nuclear fractions at 30-45 min and a decrease in signal by 60 min. A similar time course characterized recruitment by TR of p300, a coactivator protein with intrinsic transacetylase activity. Recruitment by the receptor of SRC-1, a TR coactivator that also acetylates nucleoproteins, was also demonstrated. Inhibition of the MAPK (ERK1/2) signal transduction cascade by PD 98059 blocked the acetylation of TR caused by T4. Tetraiodothyroacetic acid (tetrac) decreased T4-induced acetylation of TR. At 10(-7)M, 3,5,3'-triiodo-l-thyronine (T3) was comparably effective to T4 in causing acetylation of TR. We studied acetylation in TR that contained mutations in the DNA-binding domain (DBD) (residues 128-142) that are known to be relevant to recruitment of coactivators and to include the MAPK docking site. In response to T4 treatment, the K128A TR mutant transfected into CV-1 cells recruited p300, but not SRC-1, and was subject to acetylation. R132A complexed with SRC-1, but not p300; it was acetylated equally well in both the absence and presence of T4. S142E was acetylated in the absence and presence of T4 and bound SRC-1 under both conditions; this mutant was also capable of binding p300 in the presence of T4. There was no serine phosphorylation of TR in any of these mutants. We conclude that (1) TRbeta1, like AR and ER, is subject to acetylation; (2) the process of acetylation of TR requires thyroid hormone-directed MAPK activity, but not serine phosphorylation of TR by MAPK, suggesting that the contribution of MAPK is upstream in the activation of the acetylase; (3) the amino acid residue 128-142 region of the DBD of TR is important to thyroid hormone-associated recruitment of p300 and SRC-1; (4) acetylation of TR DBD mutants that is directed by T4 appears to be associated with recruitment of p300.

Exogenous Cushing's syndrome and glucocorticoid withdrawal.

Glucocorticoid therapy in various forms is extremely common for a wide range of inflammatory, autoimmune, and neoplastic disorders. It is therefore important for the physician to be aware of the possibility of both iatrogenic and factitious Cushing's syndrome. Although most common with oral therapy, it is also important to be alert to the fact that all forms of glucocorticoid delivery have the potential to cause Cushing's syndrome. Withdrawal from chronic glucocorticoid therapy presents significant challenges. These include the possibility of adrenal insufficiency after discontinuation of steroid therapy, recurrence of underlying disease as the glucocorticoid is being withdrawn, and the possibility of steroid withdrawal symptoms. Nonetheless, with patience and persistence, a reasonable approach to withdrawal of glucocorticoid therapy can be achieved.

Tyrosine phosphorylated Disabled 1 recruits Crk family adapter proteins.

Disabled 1 (Dab1) functions as a critical adapter protein in the Reelin signaling pathway to direct proper positioning of neurons during brain development. Reelin stimulates phosphorylation of Dab1 on tyrosines 198 and 220, and phosphorylated Dab1 is likely to interact with downstream signaling proteins that contain Src homology 2 (SH2) domains. To search for such proteins, we used a Sepharose-conjugated peptide containing phosphotyrosine 220 (PTyr-220) of Dab1, as an affinity matrix to capture binding proteins from mouse brain extracts. Mass spectrometric analysis of bound proteins revealed that Crk family adapter proteins selectively associated with this phosphorylation site. We further show that Crk-I and Crk-II, but not CrkL, stimulate phosphorylation of Dab1 on tyrosine 220 in a Src-dependent manner. Our results suggest that Crk family adapter proteins may play an important role in the Reelin signaling pathway during brain development.