Validation of coding algorithms for the identification of herpes zoster among children.

PURPOSE: To examine the validity of International Classification of Diseases, 10th Revision, (ICD-10) code-based algorithms for herpes zoster (HZ) in the electronic medical record (EMR) of a large, integrated pediatric healthcare network and to examine baseline demographics and chronic comorbidities associated with HZ in a representative pediatric population. METHODS: We reviewed the electronic charts of all patients with a single ICD-10 for HZ (B02.xx) as their primary or secondary diagnosis in the EMR of the Children's Hospital of Philadelphia (CHOP) healthcare network from January 2010-March 2019. The positive predictive value (PPV) for a single code for HZ was calculated and alternative algorithms were examined to determine which method resulted in the highest PPV. RESULTS: The PPV for a single ICD-10 code was 91.7% (95% CI 80.8-95.4) for definitive and/or probable cases of HZ and 63.9% (95% CI 53.4%-75.5%) for definitive cases alone. Adding a prescription for an antiviral did not improve the PPV. However, adding a new code for rash entered within 1 week of the HZ code increased the PPV to 100% for definitive and/or probable cases but with substantial loss of sensitivity. A high proportion of children with HZ who required inpatient hospitalization had chronic disease (70%) and were on systemic immunomodulatory therapy (50%). CONCLUSIONS: HZ can be identified with a high PPV in electronic medical records of children using ICD-10 code alone. These findings lay the foundation for future pharmacoepidemiologic research to better understand risk factors for HZ infection.

A quantitative comparison between SOX10 and MART-1 immunostaining to detect melanocytic hyperplasia in chronically sun-damaged skin.

Histologic differentiation of melanoma in situ (MIS) from solar keratosis on chronically sun-damaged skin is challenging. The first-line immunostain is usually MART-1/Melan-A, which can exaggerate the epidermal melanocytes, causing a diagnostic pitfall for MIS. By comparing MART-1 and SOX10 immunostaining, we scored the percentage of epidermal melanocytes per 2-mm diameter fields in pigmented actinic keratosis (n = 16), lichenoid keratosis (n = 7), junctional melanocytic nevus (n = 6), keratosis with atypical melanocytic proliferation (n = 17) and MIS (n = 10). These cases represented an older population (68 years median age) and the head and neck (50%) was the most common anatomic site. MART-1 score was significantly higher than SOX10 (P value <.05) in solar keratoses, but showed no difference in detecting melanocytic proliferations, demonstrating their equal detection rate of melanocytes. The sensitivity of both MART-1 and SOX10 was 100%, while their specificities were 17% and 96%, respectively. These results show that SOX10 is more specific than MART-1 in distinguishing epidermal melanocytes on sun-damaged skin by avoiding overdiagnosis of melanoma.

Cutaneous sarcoidosis masquerading as psoriatic plaques.

Sarcoidosis is a multisystem disease characterized by non-caseating granulomas present in the involved organ systems. The disease is believed to result from an interaction among genetic factors, antigens, and the immune response. Environmental exposures and infectious agents have been implicated as potential causes. Cutaneous sarcoidosis presents clinically in many forms and the lesions are classified as either specific or non-specific. Non-specific lesions show a nondescript inflammatory process whereas specific lesions display typical, non-caseating granulomas. There are many different forms of specific lesions with some being more common than others. Psoriasiform lesions are uncommon. The literature suggests that as few as 0.9% of patients display this type of cutaneous sarcoidosis. Some of these patients present solely with cutaneous sarcoidosis, but others have systemic involvement with pulmonary involvement being the most common concomitant presentation. Plaques appear as round or oval, brownish, red infiltrated lesions, frequently involving the extensor surface of the extremities, face, scalp, back, and buttocks. Multiple configurations, including discrete, confluent, annular, and polycyclic, have been reported. Despite the clinical resemblance to psoriasis, on histological examination, only non-caseating granulomas are seen in the dermis. In rare cases both psoriasiform sarcoidosis and psoriasis were present.

Dissociation between dorsal and ventral hippocampal theta oscillations during decision-making.

Hippocampal theta oscillations are postulated to support mnemonic processes in humans and rodents. Theta oscillations facilitate encoding and spatial navigation, but to date, it has been difficult to dissociate the effects of volitional movement from the cognitive demands of a task. Therefore, we examined whether volitional movement or cognitive demands exerted a greater modulating factor over theta oscillations during decision-making. Given the anatomical, electrophysiological, and functional dissociations along the dorsal-ventral axis, theta oscillations were simultaneously recorded in the dorsal and ventral hippocampus in rats trained to switch between place and motor-response strategies. Stark differences in theta characteristics were found between the dorsal and ventral hippocampus in frequency, power, and coherence. Theta power increased in the dorsal, but decreased in the ventral hippocampus, during the decision-making epoch. Interestingly, the relationship between running speed and theta power was uncoupled during the decision-making epoch, a phenomenon limited to the dorsal hippocampus. Theta frequency increased in both the dorsal and ventral hippocampus during the decision epoch, although this effect was greater in the dorsal hippocampus. Despite these differences, ventral hippocampal theta was responsive to the navigation task; theta frequency, power, and coherence were all affected by cognitive demands. Theta coherence increased within the dorsal hippocampus during the decision-making epoch on all three tasks. However, coherence selectively increased throughout the hippocampus (dorsal to ventral) on the task with new hippocampal learning. Interestingly, most results were consistent across tasks, regardless of hippocampal-dependent learning. These data indicate increased integration and cooperation throughout the hippocampus during information processing.

Changes in task demands alter the pattern of zif268 expression in the dentate gyrus.

Granule cells of the dentate gyrus (DG) are thought to disambiguate similar experiences--a process termed pattern separation. Using zif268 as a marker of cellular activity, DG function was assessed in rats performing two tasks: a place task (go east) and a response task (turn right). As these tasks occurred within the same physical space (a plus maze) without any physical cue to indicate the correct strategy in a given trial, this scenario critically involves disambiguation of task demands and presumably pattern separation. Performance of the two tasks induced zif268 expression in distinct populations of granule cells within the suprapyramidal but not the infrapyramidal blade of the DG. Repeated performance of the same task (i.e., two response-task trials or two place-task trials), however, elicited zif268 expression within a single subset of the granule cell population. This differential transcription pattern shows that the retrieval of different behavioral strategies or mnemonic demands recruit distinct ensembles of granule cells, possibly to prevent interference between memories of events occurring within the same physical space to permit the selection of appropriate responses.

Cognitive demands induce selective hippocampal reorganization: Arc expression in a place and response task.

Place cells in the hippocampus can maintain multiple representations of a single environment and respond to physical and/or trajectory changes by remapping. Within the hippocampus there are anatomical, electrophysiological, and behavioral dissociations between the dorsal and ventral hippocampus and within dorsal CA1. Arc expression was used to measure the recruitment of ensembles across different hippocampal subregions in rats trained to utilize two different cognitive strategies while traversing an identical trajectory. This behavioral paradigm allowed for the measurement of remapping in the absence of changes in external cues, trajectory traversed (future/past), running speed, motivation, or different stages of learning. Changes in task demands induced remapping in only some hippocampal regions: reorganization of cell ensembles was observed in dorsal CA1 but not in dorsal CA3. Moreover, a gradient was found in the degree of remapping within dorsal CA1 that corresponds to entorhinal connectivity to this region. Remapping was not seen in the ventral hippocampus: neither ventral CA1 nor CA3 exhibited ensemble changes with different cognitive demands. This contrasts with findings of remapping in both the dorsal and ventral dentate gyrus using this task. The results suggest that the dorsal pole of the hippocampus is more sensitive to changes in task demands.

A Resident-driven Initiative to Increase Bedside Teaching on Interdisciplinary Rounds.

Inpatient rounding serves numerous roles. The American Academy of Pediatrics recommends a family-centered bedside model. Residents identified physical examination teaching during and satisfaction with rounds as areas for improvement. A resident group developed a project utilizing quality improvement (QI) methodology to address these concerns. We aimed to increase the frequency of bedside physical examination teaching most or every day on a single inpatient unit by 20% over 1 year, with secondary goals to increase the percentage of interns spending one hour or more at bedside per day by 10% and intern satisfaction by 15%, without impacting rounding duration. METHODS: We developed an organizational structure to complete a long-term resident-led project. Interventions included daily bedside examination teaching on rounds, afternoon examinations, goal communication, topic recording, and a teaching "tip sheet." Using an institutional QI framework, we utilized iterative plan-do-study-act cycles to implement interventions and surveys to assess outcomes, with rounding efficiency as a balancing measure. RESULTS: The survey response rate was 57%. Bedside teaching frequency increased from a mean of 10% to 61%, perceived time at the bedside increased from 37% to 59%, and rounding satisfaction improved from a rating of 6.7/10 to 7.4/10. Efficiency was not impacted. CONCLUSIONS: We improved inpatient rounds bedside physical examination teaching and satisfaction without sacrificing efficiency. This project demonstrates the feasibility and success of a resident-driven education initiative to successfully motivate fellow residents and colleagues across disciplines to enact change. The organizational structure may serve as a model for resident-led QI projects across institutions.