Digital health: a neglected part of health curricula?

With growing government investment and a thriving consumer market, digital technologies are rapidly transforming our means of healthcare delivery. These innovations offer increased diagnostic accuracy, greater accessibility and reduced costs compared with conventional equivalents. Despite these benefits, implementing digital health poses challenges. Recent surveys of healthcare professionals (HCPs) have revealed marked inequities in digital literacy across the healthcare service, hampering the use of these new technologies in clinical practice. Furthermore, a lack of appropriate training in the associated ethical considerations risks HCPs running into difficulty when it comes to patient rights. In light of this, and with a clear need for dedicated digital health education, we argue that our focus should turn to the foundation setting of any healthcare profession: the undergraduate curriculum.

Type 2 Diabetes in Women: Differences and Difficulties.

BACKGROUND: Lifestyle modification, along with medication, has improved the quality of life of patients with type 2 diabetes (T2D), but the treatment of diabetes in women still lacks a gender-centric approach. METHODS: Expert opinions to improve diabetes management in women were collated from the open discussion forum organized by the sixth Jothydev's Professional Education Forum Diabetes Convention, which included global diabetes care experts and the general public. The review is also based on the studies published in electronic databases such as PubMed and Google Scholar that discussed the problems and challenges faced by the Indian diabetes care sector in treating women with diabetes. RESULTS: The complex interplay of biological, socioeconomic, psychosocial, and physiological factors in women with type 2 diabetes has not been well addressed to date. Biological factors such as neurohumoral pathways, sex hormones, genetic predisposition as well as gender-based environmental and behavioural differences must be considered for modern personalized diabetes treatment. Most importantly, pregnant women with diabetes deserve special attention. This vulnerable phase has a marked impact on the future health of both the mother and the offspring. CONCLUSION: The review provides an overview of the challenges and issues that exist in the clinical management of diabetes and its complications among women in India. Women-centric clinical approaches should be encouraged for the effective management of diabetes in Indian women.

Impact of a pharmaceutical care incentive program on the asthma medication ratio among pediatric patients with persistent asthma enrolled in a Medicaid program.

BACKGROUND: Asthma is one of the leading chronic disease states in pediatric patients in Texas. Pharmacy-led interventions such as targeted asthma education, scheduled consultations, and monitoring have shown success in improving asthma outcomes. However, no studies have evaluated the impact of the pharmaceutical care incentive (PCI) programs on Texas Medicaid pediatric beneficiaries. OBJECTIVES: To (1) describe the prevalence of asthma medication utilization and persistent asthma among Medicaid pediatric patients in Texas Health Service Region 11 (HSR 11) and (2) describe the prevalence and impact of PCI program interventions offered by pharmacists to Medicaid pediatric patients or their caregivers at the point-of-service in their medication utilization and asthma medication ratio (AMR). METHODS: This study used a 2-year longitudinal assessment of Medicaid pharmacy claims for beneficiaries aged between 0 and 18 years, with continuous enrollment, and at least 1 asthma medication claim during 2018 and 2019. The prevalence of asthma medication utilization during the study period was described. Also, the prevalence of PCI interventions among beneficiaries with at least 1 asthma medication was described. The prevalence of PCI interventions was also estimated for beneficiaries with persistent asthma. The AMR for beneficiaries with persistent asthma was calculated and compared for those with and without at least 1 PCI intervention. RESULTS: 22,051 beneficiaries with continuous enrollment between the ages of 0 and 18 years and with at least 1 pharmacy claim for an asthma medication during the study period were included. The overall prevalence of asthma medication utilization was 14.55%. 374 (1.70%) beneficiaries with at least 1 asthma medication received at least 1 asthma PCI intervention. Among beneficiaries that received at least 1 asthma PCI intervention, 158 (42.25%) were on rescue medication only; 4 (1.07%) were on maintenance medication only; and 212 (56.68%) were on rescue and maintenance medications. The overall prevalence of persistent asthma was 4.86%. 52 (0.76%) persistent asthma cases received at least 1 asthma PCI intervention after the index date. The overall unadjusted mean AMR (SD) for the 6,885 beneficiaries with persistent asthma was 0.50 (0.19). The adjusted AMR (SD) among beneficiaries with persistent asthma was reported at 0.530 (0.026) for beneficiaries who received at least 1 PCI intervention and 0.483 (0.002) for beneficiaries who did not receive a PCI intervention (P = 0.066). Beneficiaries with persistent asthma generated 64.35% of the total asthma pharmacy claims during 2019. CONCLUSIONS: Despite a high utilization of asthma medications among Medicaid pediatric beneficiaries, pharmacists servicing this group are underusing the PCI program interventions. An increase in the AMR among patients with persistent asthma receiving PCI interventions was observed when compared with those without PCI interventions. However, the difference was not statistically significant. Subsequent studies should include larger groups of beneficiaries receiving PCI interventions to establish the effect of PCI interventions on AMR before widespread implementation. DISCLOSURES: This research project was supported by the Global Institute for Hispanic Health (GIHH) through research grant M1803961. The authors have nothing to disclose. A part of this study was presented as a poster at the AMCP 2020 Virtual Annual Meeting and Exposition Meeting, April 21-24, 2020.

Prevalence of statin utilization and adherence among privately insured subjects in the Commonwealth of Puerto Rico.

BACKGROUND: Puerto Ricans are the Hispanic subgroup with the highest adjusted prevalence of statin-eligible patients. However, no study has described statin utilization and adherence among subjects living on the island of Puerto Rico. OBJECTIVES: To (a) estimate the prevalence of beneficiaries with diabetes aged between 40 and 75 years; (b) estimate the prevalence of statin utilization among beneficiaries with diabetes; and (c) estimate secondary adherence to statins among beneficiaries with diabetes. METHODS: With pharmacy claims data from a commercial pharmacy benefit manager (PBM) in the Commonwealth of Puerto Rico, this study used a retrospective longitudinal design to analyze all pharmacy claims generated by 115,674 beneficiaries aged between 40 and 75 years with continuous enrollment during 2018. Beneficiaries with diabetes were defined by having ≥ 2 pharmacy claims for antidiabetic agents during 2018. Statin utilization was defined by having ≥ 1 pharmacy claim for statins among beneficiaries with diabetes. The proportion of days covered (PDC) was used to measure secondary adherence to statins. Parametric and nonparametric statistics were used to describe statin utilization and adherence. RESULTS: The prevalence of beneficiaries with diabetes was 7.8%. Of the 8,975 beneficiaries with diabetes, 5,129 (57.1%) received ≥ 1 prescription for a statin. Older males with diabetes were more likely to receive prescriptions for statins. The median PDC for the 4,553 beneficiaries with ≥ 2 prescriptions for statins was 63.4%; 3,306 (72.6%) beneficiaries filled their statin prescriptions for a 30-day supply only; and 1,252 (27.5%) beneficiaries had a PDC ≥ 80%. The highest PDC (92.3%) was observed for beneficiaries who received statins for a 90-day supply only. CONCLUSIONS: This is the first study that has measured statin utilization and adherence among patients with diabetes living in Puerto Rico. The utilization and adherence to statins among privately insured beneficiaries with diabetes in Puerto Rico are suboptimal. Future studies should focus on understanding the reasons for the suboptimal use of statins and on potential interventions at the beneficiary and provider level to increase statin utilization. DISCLOSURES: No outside funding supported this study. The authors have no conflicts of interest or financial disclosures to disclose related to this study.

A Guide to Bacterial Culture Identification And Results Interpretation.

PURPOSE: To provide a guide to interpreting bacterial culture results. METHODS: Studies were identified via a PubMed literature search (from 1966 to January 2018). Search terms included microbial sensitivity tests, microbial drug resistance, and anti-infective agents/pharmacology. Articles were included if they were published in English. References within identified articles were also reviewed. RESULTS: This paper reviewed core concepts of interpreting bacterial culture results, including timing of cultures, common culture sites, potential for contamination, interpreting the Gram stain, role of rapid diagnostic tests, conventional antibiotic susceptibility testing, and automated testing. CONCLUSION: This guide can assist pharmacists in their role as integral members of the antimicrobial stewardship team in an effort to improve patient care.

Analysis of lip print and fingerprint patterns in patients with type II diabetes mellitus.

BACKGROUND AND OBJECTIVES: Globally, the prevalence of diabetes is soaring high in the recent times. There is an ardent search in the scientific community for a reliable and cheap early predictor which can serve the purpose of mass screening of a genetically vulnerable population. Hence, the present study was conducted to assess the predictive role of cheiloscopy on type II diabetes mellitus (T2DM). Several studies have established the association of dermatoglyphics with diabetes. However, results are still far from satisfaction. Thus, we also evaluated fingerprint analysis along with cheiloscopy. MATERIALS AND METHODS: The study was conducted on 100 uncontrolled T2DM patients and 50 healthy controls. Lip prints were obtained using lipstick and cellophane paper analyzed and classified using Suzuki and Tsuchihashi's classification. Fingerprints were obtained using kajal stick, analyzed and classified using Henry's system of classification. RESULTS: Type IV pattern of lip prints was found significantly more in the diabetic patients. Howbeit, fingerprint analysis did not reveal any significant association with diabetes. CONCLUSION: The present study showed a ray of hope for application of cheiloscopy as a potential biomarker in the early diagnosis of T2DM which can be used in mass screening. Further studies are warranted to confirm the findings.

Is the Combination of Piperacillin-Tazobactam and Vancomycin Associated with Development of Acute Kidney Injury? A Meta-analysis.

STUDY OBJECTIVE: To evaluate the association of the development of acute kidney injury (AKI) when piperacillin-tazobactam is used in combination with vancomycin compared with vancomycin with or without a ß-lactam. DESIGN: Meta-analysis of 15 observational cohort studies. PATIENTS: A total of 3258 adult inpatients who received vancomycin + piperacillin-tazobactam versus vancomycin alone (10 studies); vancomycin + piperacillin-tazobactam versus vancomycin + ß-lactam (four studies); or vancomycin + piperacillin-tazobactam versus vancomycin alone or vancomycin + other antibiotics (one study). MEASUREMENTS AND MAIN RESULTS: The PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases, as well as meeting proceedings, were searched (1966-June 1, 2016). Quality of studies was assessed by using the Newcastle-Ottawa Quality Assessment Scale (NOQAS). The primary outcome of this meta-analysis was to evaluate the association of development of AKI with the combined use of piperacillin-tazobactam and vancomycin. A subgroup analysis was also performed that examined the outcome by comparison groups (vancomycin alone or vancomycin + ß-lactam). Sensitivity analysis was performed to explore if the results differed based on removal of abstracts and removal of low-quality studies (NOQAS scores of 6 or lower). All analyses were performed using the random effects model. NOQAS scores for the 15 studies ranged from 3-7 points (of a total of 9). Overall, there was an association with the development of AKI with vancomycin + piperacillin-tazobactam compared with vancomycin ± ß-lactam (odds ratio [OR] 3.649, 95% confidence interval [CI] 2.157-6.174; I2 = 83.5%, p<0.001). The association remained significant when abstracts were removed (OR 3.498, 95% CI 1.747-7.003, I2 = 82.3%, p<0.001) and when low-quality studies were removed (OR 4.596, 95% CI 2.929-7.212, I2 = 0%, p<0.001). The association for the development of AKI with vancomycin + piperacillin-tazobactam compared with vancomycin alone was significant (OR 3.980, 95% CI 2.749-5.763, I2 = 31.4%, p<0.001), although the association did not remain significant for the vancomycin + ß-lactam subgroup (OR 3.029, 95% CI 0.942-9.738, I2 = 82.3%, p=0.063). CONCLUSION: Vancomycin + piperacillin-tazobactam was associated with an increased risk of AKI compared with vancomycin ± ß-lactam. Practitioners need to be vigilant about this association when prescribing this combination of antibiotics.

The Role of Smoking as a Modifiable Risk Factor in Diabetic Nephropathy.

OBJECTIVE: To study the relation of smoking and abnormal renal function in type 2 diabetes mellitus by estimating urine protein- creatinine ratio, blood urea, serum creatinine, glomerular filtration rate and serum lipid profile in selected subjects. METHODS: Diabetic patients who attended the Diabetic Clinic, Medical College, Kozhikode were enrolled in the study. The study duration was 6 months, from July 2008 to December 2008. It was conducted in four groups of 40 subjects: diabetic smokers, diabetic non-smokers, non-diabetic smokers and non-diabetic non-smokers. The parameters assayed were: Blood urea, Serum creatinine, Fasting Blood Glucose and Serum Lipid Profile. The parameters assayed in the different groups were compared. Logistic regression analysis was done to study the effect of smoking on renal function. RESULTS: The mean difference of Urine protein- creatinine ratio between diabetic smokers and non-diabetic smokers is statistically significant (0.46±0.21 vs 0.24±0.14, p<0.001). The mean differences of Blood Urea between all the groups are statistically significant. The mean difference of Serum Creatinine of diabetic smokers with non-diabetic smokers is statistically significant (1.2±0.5 vs 0.96±0.2, p<0.05). The mean differences of Total Cholesterol, Triglycerides, HDL, LDL and VLDL between all the study groups is statistically significant. In the regression analysis, it was found that 12.9% of the alteration of renal function can be explained by smoking alone. (R2 = 0.129). CONCLUSIONS: Smoking is an independent risk factor for progression of diabetic nephropathy. 24.8% of deterioration of renal function can be explained by smoking, obesity, hypertension and dyslipidemia and 12.9% of the alteration of renal function by smoking alone.

Integrative analysis of diffusion-weighted MRI and genomic data to inform treatment of glioblastoma.

Gene expression profiling from glioblastoma (GBM) patients enables characterization of cancer into subtypes that can be predictive of response to therapy. An integrative analysis of imaging and gene expression data can potentially be used to obtain novel biomarkers that are closely associated with the genetic subtype and gene signatures and thus provide a noninvasive approach to stratify GBM patients. In this retrospective study, we analyzed the expression of 12,042 genes for 558 patients from The Cancer Genome Atlas (TCGA). Among these patients, 50 patients had magnetic resonance imaging (MRI) studies including diffusion weighted (DW) MRI in The Cancer Imaging Archive (TCIA). We identified the contrast enhancing region of the tumors using the pre- and post-contrast T1-weighted MRI images and computed the apparent diffusion coefficient (ADC) histograms from the DW-MRI images. Using the gene expression data, we classified patients into four molecular subtypes, determined the number and composition of genes modules using the gap statistic, and computed gene signature scores. We used logistic regression to find significant predictors of GBM subtypes. We compared the predictors for different subtypes using Mann-Whitney U tests. We assessed detection power using area under the receiver operating characteristic (ROC) analysis. We computed Spearman correlations to determine the associations between ADC and each of the gene signatures. We performed gene enrichment analysis using Ingenuity Pathway Analysis (IPA). We adjusted all p values using the Benjamini and Hochberg method. The mean ADC was a significant predictor for the neural subtype. Neural tumors had a significantly lower mean ADC compared to non-neural tumors ([Formula: see text]), with mean ADC of [Formula: see text] and [Formula: see text] for neural and non-neural tumors, respectively. Mean ADC showed an area under the ROC of 0.75 for detecting neural tumors. We found eight gene modules in the GBM cohort. The mean ADC was significantly correlated with the gene signature related with dendritic cell maturation ([Formula: see text], [Formula: see text]). Mean ADC could be used as a biomarker of a gene signature associated with dendritic cell maturation and to assist in identifying patients with neural GBMs, known to be resistant to aggressive standard of care.

Extra pulmonary tuberculosis presenting as fever with massive splenomegaly and pancytopenia.

Disseminated tuberculosis is an important differential diagnosis for fever of unknown origin (FUO) and it can present with hepatosplenomegaly and lymphadenopathy and may have meningitis and with hematological abnormalities including pancytopenia or a leukemoid reaction. We report the case of a 13-year old male who presented with fever, weight loss, pallor and massive splenomegaly with pancytopenia, in whom a bone marrow trephine biopsy showed caseating granulomata, who responded well to antituberculous treatment and has remained healthy on follow up after nine years.

Cytokine gene polymorphism (interleukin-1ß +3954, Interleukin-6 [-597/-174] and tumor necrosis factor-α -308) in chronic periodontitis with and without type 2 diabetes mellitus.

BACKGROUND: Pro-inflammatory cytokine gene polymorphisms are potential candidates for susceptibility for both type 2 diabetes mellitus (DM) and chronic periodontitis (CHP). This study explored the association of interleukin-1 beta (IL-1 ß) +3954, interleukin-6 (IL-6) -597/-174 and tumor necrosis factor-alpha (TNF-α) -308 single nucleotide polymorphisms in CHP with and without type 2 DM in Malayalam speaking subjects of Dravidian ethnicity. MATERIALS AND METHODS: This case control study consisted of 51 chronic periodontitis with type 2 diabetes mellitus (CHPDM) and 51 CHP patients as cases and 51 healthy subjects as controls. Polymorphisms were identified by polymerase chain reaction amplification followed by restriction enzyme digestion and gel electrophoresis. RESULTS: IL-1 ß (+3954) TT genotype and T allele were significantly associated with CHPDM group when compared with CHP (P = 0.001), whereas CC genotype and allele C was higher in CHP subjects (P = 0.001). For IL-6 (-597) frequency of genotype GA/AA (P = 0.04) and allele A (P = 0.01) was lower in CHPDM group, and for TNF-α -308 the frequency of genotype GA (P = 0.01) and allele A (P = 0.01) was higher in CHP subjects when compared with controls. CONCLUSIONS: In Malayalam speaking Dravidian population, IL-6 (-597) genotype GA/AA and allele A appears to be protective for CHP with type 2 DM. Allele C of IL-1 ß +3954 and allele A of TNF-α -308 appears to be risk factors for CHP individuals.

Hypertension as a Risk Factor for Haemorrhagic Stroke in Females.

AIM: To study the effect of hypertension as a risk factor for haemorrhagic stroke in women compared to men. METHOD: Confirmed cases of haemorrhagic stroke by Computed Tomography scan were included in this study. The participants underwent detailed clinical examination based on preset questionnaire. Relevant laboratory investigations were done in this group. 100 consecutive cases were studied comparing the baseline characteristics with male patients admitted with haemorrhagic stroke. OBSERVATIONS: Among all the risk factors studied hypertension was the single most important risk factor causing intracerebral bleed. Forty seven point four percentage (47.4%) of females were hypertensive as against 61% in males. Blood pressure recording of females showed lower systolic and diastolic measurement compared to males and the difference was statistically significant with a p value of 0.000. Majority of the female patients were overweight with a significant difference in body mass index compared to males. (p value 0.006). CONCLUSION: Hypertension is an important risk factor for intracerebral bleed. Females developed intracerebral bleed at a lower blood pressure measurement compared to males. Females require better control of hypertension than males to prevent intracerebral bleed.

Carotid artery intima media thickness in relation with atherosclerotic risk factors in patients with type 2 diabetes mellitus.

The present study was carried out to study the correlation between carotid artery intima media thickness (CIMT) with risk factors for atherosclerosis and atherosclerotic events in Type 2 Diabetes mellitus patients. The predictive value of CIMT as an indicator of early atherosclerosis was determined and the various atherosclerotic risk factors in type 2 diabetes mellitus were studied. Our study showed that CIMT was significantly higher in those type 2 diabetic patients who had atherosclerotic events than in those patients who had no atherosclerotic events. It was also found that waist hip ratio showed a significant positive correlation and independent association with CIMT emphasizing the emerging concept of central obesity. Duration of diabetes, urinary albumin excretion rate, hypertension and glycated hemoglobin had positive correlation with CIMT, but could not assume statistical significance. Age, smoking and dyslipidemia did not show any association with CIMT.