Assessing the Effect of Electronic Health Record Data Quality on Identifying Patients with Type 2 Diabetes.

BACKGROUND: Increasing and substantial reliance on Electronic health records (EHR) and data types (i.e., diagnosis (Dx), medication (Rx), laboratory (Lx)) demands assessment of its data quality (DQ) as a fundamental approach; especially since there is need to identify appropriate denominator population with chronic conditions, such as Type-2 Diabetes (T2D), using commonly available computable phenotype definitions (phenotype). OBJECTIVE: To bridge this gap, our study aims to assess how issues of EHR DQ, and variations and robustness (or lack thereof) in phenotypes may have potential impact in identifying denominator population. METHODS: Approximately 208k patients with T2D were included in our study using retrospective EHR data of Johns Hopkins Medical Institution (JHMI) during 2017-2019. Our assessment included 4 published phenotypes, and 1 definition from a panel of experts at Hopkins. We conducted descriptive analyses of demographics (i.e., age, sex, race, ethnicity), healthcare utilization (inpatient and emergency room visits), and average Charlson Comorbidity score of each phenotype. We then used different methods to induce/simulate DQ issues of completeness, accuracy and timeliness separately across each phenotype. For induced data incompleteness, our model randomly dropped Dx, Rx, and Lx codes independently at increments of 10%; for induced data inaccuracy, our model randomly replaced a Dx or Rx code with another code of the same data type and induced 2% incremental change from -100% to +10% in Lx result values; and lastly, for timeliness, data was modeled for induced incremental shift of date records by 30 days up to a year. RESULTS: Less than a quarter (23%) of population overlapped across all phenotypes using EHR. The population identified by each phenotype varied across all combination of data types. Induced incompleteness identified fewer patients with each increment, for e.g., at 100% diagnostic incompleteness, Chronic Conditions Data Warehouse (CCW) phenotype identified zero patients as its phenotypic characteristics included only Dx codes. Induced inaccuracy and timeliness similarly demonstrated variations in performance of each phenotype and therefore, resulting in fewer patients being identified with each incremental change. CONCLUSIONS: We utilized EHR data with Dx, Rx, and Lx data types from a large tertiary hospital system to understand the T2D phenotypic differences and performance. We learned how issues of DQ, using induced DQ methods, may impact identification of the denominator populations upon which clinical (e.g., clinical research and trials, population health evaluations) and financial/operational decisions are made. The novel results from our study may inform in shaping a common T2D computable phenotype definition that can be applicable to clinical informatics, managing chronic conditions, and additional healthcare industry-wide efforts.

An efficient Agrobacterium-mediated genetic transformation method for foxtail millet (Setaria italica L.).

KEY MESSAGE: A simple and robust Agrobacterium-mediated gene expression system in the C4 panicoid model crop, foxtail millet has been developed with up to 27 % transformation efficiency. Foxtail millet (Setaria italica L.) is a model crop to study C4 photosynthesis, abiotic stress tolerance, and bioenergy traits. Advances in molecular genetics and genomics had identified several potential genes in this crop that would serve as candidates for imparting climate-resilient traits in related millets, cereals, and biofuel crops. However, the lack of an efficient genetic transformation system has been impeding the functional characterization of these genes in foxtail millet per se. Given this, an easy and efficient regeneration and transformation protocol was optimized using mature seeds as a choicest explant. The suitability of secondary embryogenic calli over primary calli is underlined due to their high competence. The use of perfect combinations of plant growth regulators together with the ionic strength of organic and inorganics salts was found to influence regeneration and genetic transformation. We studied and optimized various crucial factors that affect the genetic transformation of foxtail millet calli using Agrobacterium tumefaciens-mediated approach. Secondary embryogenic calli and LBA44404 strain were found to be the best targets for transformation. The use of high sucrose and glucose, together with freshly prepared tobacco leaves extract, Silwet L-77 and acetosyringone, improved the efficiency of the genetic transformation of foxtail millet. Moreover, the use of an in vitro regeneration system with 84% callusing efficiency and 70-74% regeneration frequency led to a high recovery of transformants. Altogether, the present study reports a highly efficient (~ 27%) transformation system in foxtail millet that will expedite forward and reverse genetic studies in this important crop.

Bioconversion of acrylonitrile using nitrile hydratase activity of Bacillus sp. APB-6.

Bacillus sp. APB-6 harboring nitrile hydratase was used in the production of acrylamide from acrylonitrile. Bacillus sp. APB-6, for maximum production of Co++ containing nitrile hydratase, was cultured in the medium containing lactose (18.0 g l-1), peptone (1.0 g l-1), yeast extract (2.0 g l-1), MgSO4 (0. 5 g l-1), K2HPO4 (0.6 g l-1), urea (9.0 g l-1), and CoCl2 (0.01 g l-1), pH 7.0, and incubated at 35 °C for 24 h in an incubator shaker (160 rpm). Nitrile hydratase exhibited relatively high specificity for aliphatic nitriles. Free cells were immobilized using 2% (w/v) agar solution to enhance enzyme stability and reusability in repetitive cycles of acrylamide production. Under optimized conditions, nearly complete bioconversion of acrylonitrile was achieved with a fair recovery of 85% using free and immobilized cells equivalent to 500 mg dcw l-1. An efficient nitrile hydratase-mediated bioconversion of acrylonitrile to acrylamide at 1-l scale was achieved with time and space productivity of 426 g h-1 g-1 dcw using free cells.

Efficacy of Dexmedetomidine in two Different Doses as an Adjuvant to Lignocaine in Patients Scheduled for Surgeries under Axillary Block.

INTRODUCTION: The effect of adding dexmedetomidine (α2-adrenoceptor agonist) to local anaesthetics in brachial plexus blocks has been evaluated, however there has been no consensus regarding the ideal dose of dexmedetomidine. Without ultrasound axillary block has been considered as the safest approach for brachial block. AIM: To evaluate the efficacy of two doses of dexmedetomidine (0.5 µg/kg and 1 µg/kg) as an adjuvant to lignocaine in patients undergoing forearm surgeries under axillary brachial plexus block. MATERIALS AND METHODS: This prospective randomized controlled study was conducted on 104 adult patients, American Society of Anaesthesiologists (ASA) physical status 1 or 2. They were randomized and given following drug formulations, Group L (n=35) received 23 ml of 2% lignocaine with adrenaline + 7 ml of saline, Group LD0.5 (n=34) received 23 ml of 2% lignocaine with adrenaline + 0.5 µg/kg of dexmedetomidine diluted in saline to make a volume of 7 ml, Group LD1 (n=35) was given 23 ml of 2% lignocaine with adrenaline + 1 µg/kg of dexmedetomidine diluted in saline to make volume of 7 ml, the total volume of drug being 30 ml in each group and concentration of lignocaine 1.5%. The duration of postoperative analgesia and demand for rescue analgesia were the primary outcomes and block characteristics taken as secondary outcome. RESULTS: Sensory and motor block onset times were shorter in Group L than in group LD0.5, LD1 (p < 0.05). Sensory and motor blockade durations were longer in Group LD1, LD0.5 than Group L (p<0.01). Duration of analgesia was longer in Group LD1 than in group LD0.5 and least in Group L (p<0.05). CONCLUSION: Dexmedetomidine (0.5 µg/kg and 1 µg/kg) as an adjuvant in axillary brachial plexus increases the duration of postoperative analgesia and delays the requirement of first dose of analgesic in a dose dependent manner and 1 µg/kg seems to be the near ideal dose of dexmedetomidine as an adjuvant in axillary block.

Clinical Experience With PROSE Fitting: Significance of Diagnosis and Age.

OBJECTIVE: To compare ease of adoption of the BostonSight Prosthetic Replacement of the Ocular Surface Ecosystem device, a custom-fit scleral lens, by patients in different age and diagnosis groups. METHODS: In this prospective study, patients were categorized by age as younger than 60 or 60 years and older and by diagnosis as corneal irregularity (CI) or ocular surface disease (OSD). Ease of adoption of the scleral device was assessed by (1) number of devices and visits required to complete the fitting process, (2) time needed for device insertion and removal, (3) adaptation to the device, as assessed by daily wear time and by time needed to achieve full-time wear (defined as 8 hours per day), and (4) patients' subjective rating of ease of device insertion and removal. The length of the fitting process was also assessed. RESULTS: There was no significant difference in the number of devices and visits needed between age group younger than 60 and age group of 60 and older or between CI and OSD groups. Patients in all groups achieved full-time wear in less than 2 weeks. Average wear time per week did not differ significantly between age or diagnosis groups. Similarly, the time needed for daily insertion and removal during the fitting period, as well as patients' subjective rating of ease of device insertion and removal, did not differ between age or diagnosis categories. The length of the fitting process was significantly longer in the OSD group compared with the CI group (P<0.001); however, factors not related to ease of adoption of the scleral device may be responsible for this difference. CONCLUSIONS: Patients in both younger and older patient groups adopted the use of a scleral device with equal ease, as did patients in the CI and OSD diagnosis groups.

Corneal nerve structure and function after long-term wear of fluid-filled scleral lens.

PURPOSE: The aim of this study was to determine whether long-term wear of a fluid-filled scleral lens alters basal tear production, corneal sensation, corneal nerve density, and corneal nerve morphology in 2 disease categories. METHODS: Patients recruited from the Prosthetic Replacement of the Ocular Surface Ecosystem (PROSE) treatment program at the Weill Cornell Medical College were categorized into 2 groups: distorted corneas (DC) or ocular surface disease (OSD). We measured tear production, central corneal sensation, subbasal nerve density and tortuosity, and stromal nerve thickness before and after long-term wear of the prosthetic device used in PROSE treatment, defined as at least 60 days of wear for a minimum of 8 hours a day. RESULTS: Twenty patients were included in the study. After long-term wear of the prosthetic device, tear production decreased in patients with DC (21.2 ± 8.5 to 10.4 ± 4.6 mm; P < 0.0001) but did not change in patients with OSD (7.5 ± 5.2 to 8.7 ± 7.2 mm; P = 0.71). Corneal sensation increased in the DC group (45.6 ± 9.2 to 55.0 ± 5.6 mm; P < 0.05). There was no significant change in sensation in patients with OSD (45.0 ± 8.7 to 49.1 ± 14.8 mm; P = 0.37). Subbasal nerve density, subbasal nerve tortuosity, and stromal nerve thickness remained unchanged in both DC and OSD groups after long-term wear (P > 0.05). CONCLUSIONS: Patients with DC had significantly reduced basal tear production and increased corneal sensation after long-term wear of the scleral lens, but patients with OSD did not show any changes in tear production or corneal sensation.

Treatment of Refractory Persistent Corneal Epithelial Defects: A Standardized Approach Using Continuous Wear PROSE Therapy.

PURPOSE: To evaluate continuous wear of a fluid-ventilated, gas-permeable scleral PROSE device using a standardized protocol as treatment for refractory persistent corneal epithelial defects in patients with severe ocular surface disease. METHODS: Retrospective review of eight eyes of seven consecutive patients with persistent epithelial defects refractory to traditional therapies. The standardized treatment regimen consisted of: (1) 24-hour-a-day PROSE wear until re-epithelialization was achieved, (2) brief daily device removal, cleaning, disinfection, and reservoir fluid replacement, (3) addition of a benzalkonium chloride (BAK)-free fourth-generation fluoroquinolone antibiotic drop to the reservoir, and (4) transition to long-term, daytime PROSE wear upon re-epithelialization. RESULTS: All eight eyes exhibited resolution of the persistent epithelial defect. No eyes developed microbial keratitis. Four eyes exhibited recurrences; all recurrences promptly responded to reinstitution of continuous wear. CONCLUSIONS: Continuous wear of a PROSE device, using a strictly standardized regimen, constitutes an effective, safe treatment option for refractory persistent epithelial defects.

Boston type I keratoprosthesis-donor cornea interface evaluated by high-definition spectral-domain anterior segment optical coherence tomography.

BACKGROUND: The purpose of this study was to assess whether the resolution offered by two different, recently commercially available high-resolution, spectral-domain anterior segment optical coherence tomography (AS-OCT) instruments allows for detailed anatomic characterization of the critical device-donor cornea interface in eyes implanted with the Boston type I permanent keratoprosthesis. METHODS: Eighteen eyes of 17 patients implanted with the Boston type I keratoprosthesis were included in this retrospective case series. All eyes were quantitatively evaluated using the Cirrus HD-OCT while a subset (five eyes) was also qualitatively imaged using the Spectralis Anterior Segment Module. Images from these instruments were analyzed for evidence of epithelial migration onto the anterior surface of the keratoprosthesis front plate, and presence of a vertical gap between the posterior surface of the front plate and the underlying carrier donor corneal tissue. Quantitative data was obtained utilizing the caliper function on the Cirrus HD-OCT. RESULTS: The mean duration between AS-OCT imaging and keratoprosthesis placement was 29 months. As assessed by the Cirrus HD-OCT, 83% of eyes exhibited epithelial migration over the edge of the front plate. Fifty-six percent of the keratoprosthesis devices displayed good apposition of the device with the carrier corneal donor tissue. When a vertical gap was present (44% of eyes), the mean gap was 40 (range 8-104) microns. The Spectralis Anterior Segment Module also displayed sufficient resolution to allow for similar characterization of the device-donor cornea interface. CONCLUSION: Spectral-domain AS-OCT permits high resolution imaging of the keratoprosthesis device-donor cornea interface. Both the Cirrus HD-OCT and the Spectralis Anterior Segment module allowed for visualization of epithelial coverage of the device-donor cornea interface, as well as identification of physical gaps. These imaging modalities, by yielding information in regard to integration of the keratoprosthesis with surrounding corneal tissue, may help identify those at risk for keratoprosthesis-related complications, such as extrusion and endophthalmitis, and hence guide clinical management.

Patient acceptability of the Tecnis multifocal intraocular lens.

Cataract surgery has evolved. The goal of the surgeon includes both restoration of vision and refinement of vision. Patients' desire for spectacle independence has driven the market for presbyopia-correcting cataract surgery and development of novel intraocular lens (IOL) designs. The Tecnis(®) Multifocal Intraocular Lens incorporates an aspheric, modified anterior prolate IOL with a diffractive multifocal lens design. The design aims to minimize spherical aberration and improve range of focus. The purpose of this review is to assess patient acceptability of the Tecnis(®) multifocal intraocular lens.

The roles of plant phenolics in defence and communication during Agrobacterium and Rhizobium infection.

Phenolics are aromatic benzene ring compounds with one or more hydroxyl groups produced by plants mainly for protection against stress. The functions of phenolic compounds in plant physiology and interactions with biotic and abiotic environments are difficult to overestimate. Phenolics play important roles in plant development, particularly in lignin and pigment biosynthesis. They also provide structural integrity and scaffolding support to plants. Importantly, phenolic phytoalexins, secreted by wounded or otherwise perturbed plants, repel or kill many microorganisms, and some pathogens can counteract or nullify these defences or even subvert them to their own advantage. In this review, we discuss the roles of phenolics in the interactions of plants with Agrobacterium and Rhizobium.