A case of diabetic striatopathy due to uncontrolled type 2 diabetes.

Summary: Hemichorea-hemiballismus (HCHB) syndrome is a syndrome characterized by choreic movements which are irregular, nonrepetitive, and random movements, and ballismus which are spontaneous and violent movements. HCHB syndrome with a metabolic cause is a rare presentation that can be precipitated by uncontrolled diabetes. Presented here is a case of HCHB syndrome with right-sided neuroimaging findings and contralateral chorea due to uncontrolled type 2 diabetes mellitus. This patient was found to be obtunded with a blood glucose of greater than 500 mg/dL by EMS. After the administration of insulin, she was able to answer clarifying questions of noncompliance with her antihyperglycemic medications. She had a computed tomography without contrast of the head which showed hyperdense lesions in the right caudate nucleus and putamen consistent with HCHB syndrome. She was started on treatment for nonketotic hyperglycemia with insulin. As her mentation improved, she was able to cooperate with physical examination, which revealed irregular and violent movements in the left upper and lower extremities. Her hemichorea and hemiballismus improved with strict glycemic control, and she was able to be discharged to a skilled nursing facility for further rehabilitation. She would later have repeated hospitalizations for poor glycemic control, and repeat neuroimaging would reveal the resolution of hyperdensities after 4 months. HCHB syndrome due to uncontrolled diabetes has been termed diabetic striatopathy and is characterized by poor glycemic control, unilateral striatal hyperdensity on CT imaging, and contralateral choreic movements. Diabetic striatopathy remains a poorly understood disease, and the exact pathophysiologic mechanism has not been definitively elucidated. Learning points: Diabetic striatopathy is a relatively new term for metabolic etiology of hemichorea-hemiballismus syndrome and was coined in 2009. The triad for diabetic striatopathy is poor glycemic control, unilateral striatal hyperdensity on CT imaging, and contralateral choreic movements. Multiple etiologies have been suggested for the cause of diabetic striatopathy including petechial hemorrhage, mineral deposition, myelin destruction, and infarction with reactive astrocytosis; however, the exact mechanism has yet to be determined. Antidopaminergic medications may be used to control the choreic movements of diabetic striatopathy; however, the mainstay of treatment is glycemic control, often with insulin therapy.

Accurate and dynamic predictive model for better prediction in medicine and healthcare.

INTRODUCTION: Information and communication technologies (ICTs) have changed the trend into new integrated operations and methods in all fields of life. The health sector has also adopted new technologies to improve the systems and provide better services to customers. Predictive models in health care are also influenced from new technologies to predict the different disease outcomes. However, still, existing predictive models have suffered from some limitations in terms of predictive outcomes performance. AIMS AND OBJECTIVES: In order to improve predictive model performance, this paper proposed a predictive model by classifying the disease predictions into different categories. To achieve this model performance, this paper uses traumatic brain injury (TBI) datasets. TBI is one of the serious diseases worldwide and needs more attention due to its seriousness and serious impacts on human life. CONCLUSION: The proposed predictive model improves the predictive performance of TBI. The TBI data set is developed and approved by neurologists to set its features. The experiment results show that the proposed model has achieved significant results including accuracy, sensitivity, and specificity.

Prevalence of biopsy-proven non-alcoholic fatty liver disease in severely obese subjects without metabolic syndrome.

Obesity is a major risk factor for non-alcoholic fatty liver disease (NAFLD). NAFLD encompasses simple fatty liver (FL) and non-alcoholic steatohepatitis (NASH) in its spectrum. NASH can progress to liver cirrhosis and is associated with liver cancer. Not all obese subjects have insulin resistance (IR) or develop metabolic syndrome (MS). This study evaluates the prevalence of NAFLD in severely obese subjects without MS. We retrospectively reviewed 445 charts from our database of severely obese subjects with clinical suspicion of NAFLD and who were selected for laparoscopic Roux-en-Y gastric bypass surgery. One hundred five subjects who did not have MS, as defined by the International Diabetes Foundation, based on comprehensive pre-operative metabolic evaluation were included. Liver biopsy specimens were evaluated for NAFLD. 24% of morbidly obese (mean body mass index [BMI] 48 kg m(-2) ) adult subjects (mean age 38 years) who underwent bariatric surgery did not have MS. NAFLD was identified in 77 (73%) on liver biopsy, out of which 59 (56%) were labelled as FL and 18 (17%) had histological diagnosis of NASH. Age, gender, race and BMI were the same among all groups. Among NAFLD subjects, 22% did not have any additional metabolic component of MS, while 36% had low high-density lipoprotein, 27% had hypertension, 8% had high triglycerides and 6% had hyperglycaemia. IR calculated by HOMA-IR (Homeostatic Model Assessment for Insulin Resistance) and diagnosis of hyperglycaemia was statistically higher in NASH group compared to those who did not have NASH. NAFLD is highly prevalent in morbidly obese individuals who undergo bariatric surgery despite the absence of MS. Diagnosis of hyperglycaemia in such subjects suggests the presence of IR and may have underlying NASH, which is a progressive form of NAFLD.

Successful Treatment of Chronic Hepatitis C Infection With Direct-Acting Antivirals in a Heart Transplant Recipient: A Case Report.

BACKGROUND: Heart transplant (HT) recipients with chronic hepatitis C virus (HCV) infection are noted to have higher rates of HCV related morbidity and mortality. Treatment of HCV in the past was fraught with low cure rates, increased risk of graft rejection, and medication-related side effects. CASE REPORT: We report a case of successful treatment of HCV infection in a HT recipient. The patient was found to have HCV during his pretransplant workup. He underwent uneventful orthotopic HT in 2000. The HCV infection was monitored with regular liver enzymes and the surveillance liver biopsies at 2 and 5 years after HT showed mild but stable liver disease, and he stayed on chronic immunosuppression. He was not offered interferon-based HCV therapy because of the risk of steroid-resistant graft failure and cardiac decompensation. With the availability of the new direct-acting antivirals (DAA) for HCV infection, and worsening of liver fibrosis on noninvasive testing, we treated him with sofosbuvir and simeprevir for 12 weeks. During treatment, he remained clinically stable from a cardiac standpoint and he showed biochemical improvement in his liver and renal functions. Tacrolimus levels remained stable and did not require any dose adjustment. He showed rapid virologic response and subsequently achieved sustained virologic response at 12 weeks. CONCLUSION: DAA use was safe and effective in treating HCV infection in a HT recipient.

Characteristics of the positive ion source at reduced gas feed.

The neutral beam injector of steady state superconducting tokamak (SST1-NBI) at IPR is designed for injecting upto 1.7 MW of neutral beam (Hº, 30-55 keV) power to the tokamak plasma for heating and current drive. Operations of the positive ion source (PINI or Plug-In-Neutral-Injector) of SST1-NBI were carried out on the NBI test stand. The PINI was operated at reduced gas feed rate of 2-3 Torr l/s, without using the high speed cryo pumps. Experiments were conducted to achieve a stable beam extraction by optimizing operational parameters namely, the arc current (120-300 A), acceleration voltage (16-40 kV), and a suitable control sequence. The beam divergence, power density profiles, and species fractions (H(+):H2(+):H3(+)) were measured by using the diagnostics such as thermal calorimetry, infrared thermography, and Doppler shift spectroscopy. The maximum extracted beam current was about 18 A. A further increase of beam current was found to be limited by the amount of gas feed rate to the ion source.

Evaluation of an Emerging Research Center: Lessons Learned.

PROBLEM STATEMENT: Rigorous evaluation assures that research endeavors meet their purpose and achieve stated goals. This is especially true for federally funded exploratory research centers, which tend to be more complex due to the involvement of multiple, interdisciplinary investigators. This study provides an overview of the approach used to develop an evaluation strategy and reports the lessons learned during the initial development of the Center for Ohana Self-Management of Chronic Illness (COSMCI) at the University of Hawai'i at Manoa School of Nursing and Dental Hygiene. The COSMCI is composed of an interdisciplinary team of researchers and practitioners and aims to advance knowledge in the field of self management of chronic disease in the community setting. APPROACH: A systematic approach was utilized that included formative and summative strategies for ongoing evaluation. The problem was solved by addressing five key concerns: (1) development of research structure, (2) observing the process of the research pilot projects, (3) scholarly activity of COSMCI faculty, (4) dissemination and translation and (5) sustainability prospects. The method of research included formulating process strategies and determine if the plans for developing the Center were followed and whether these plans were effective. Interviews were also conducted at year one and at mid-point though the project. RESULTS: Themes that emerged from our evaluation included inclusion, timelines, realistic expectations, ongoing evaluation and preparing for changes in the team. This provided timely recognition of successes and challenges and facilitated a rapid response for interventions especially during the early development stage of the center. CONCLUSION/RECOMMENDATIONS: Effective development of a successful Center is highly dependent upon having a strong evaluation process in place that can inform ongoing development. An exploratory research center requires ongoing evaluation that allows for celebration of successes, as well as early identification of problems and rapid response.

The Cataract National Dataset electronic multi-centre audit of 55,567 operations: risk indicators for monocular visual acuity outcomes.

AIMS: To report risk factors for visual acuity (VA) improvement and harm following cataract surgery using electronically collected multi-centre data conforming to the Cataract National Dataset (CND). METHODS: Routinely collected anonymised data were remotely extracted from the electronic patient record systems of 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were performed to identify risk indicators for: (1) a good acuity outcome (VA 6/12 or better), (2) the pre- to postoperative change in VA, and (3) VA loss (doubling or worse of the visual angle). RESULTS: In all, 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations. Preoperative VA was known for 55,528 (99.9%) and postoperative VA outcome for 40,758 (73.3%) operations. Important adverse preoperative risk indicators found in at least 2 of the 3 analyses included older age (3), short axial length (3), any ocular comorbidity (3), age-related macular degeneration (2), diabetic retinopathy (3), amblyopia (2), corneal pathology (2), previous vitrectomy (2), and posterior capsule rupture (PCR) during surgery (3). PCR was the only potentially modifiable adverse risk indicator and was powerfully associated with VA loss (OR=5.74). CONCLUSION: Routinely collected electronic data conforming to the CND provide sufficient detail for identification and quantification of preoperative risk indicators for VA outcomes of cataract surgery. The majority of risk indicators are intrinsic to the patient or their eye, with a notable exception being PCR during surgery.

Systemic inflammation and survival of patients with prostate cancer: evidence from the Glasgow Inflammation Outcome Study.

BACKGROUND: There is some evidence that systemic inflammation may be associated with survival in patients with prostate cancer; however, it is unclear whether this is independent of grade. We therefore investigated the role of inflammation-based prognostic scores, the modified Glasgow Prognostic Score (mGPS) and neutrophil lymphocyte ratio (NLR), and their associations with Gleason grade in patients with prostate cancer. METHODS: Patients from a cohort, the Glasgow Inflammation Outcome Study, who had diagnosis of prostate cancer, were included in this study. The mGPS was constructed by combining C-reactive protein and albumin whereas NLR by calculating the ratio of neutrophils to lymphocytes. We estimated 5-year relative survival and relative excess risk (RER) of death by mGPS and NLR categories after adjusting for age, socioeconomic circumstances and Gleason grade. RESULTS: In all, 897 prostate cancer patients were identified; of those 422 (47%) died during a maximum follow-up of 6.2 years. Systemic inflammation appeared to have significant prognostic value. The mGPS predicted poorer 5-year overall and relative survival independent of age, socioeconomic circumstances, disease grade and NLR. Raised mGPS also had a significant association with excess risk of death (mGPS 2: RER =2.41, 95% confidence interval 1.37-4.23) among aggressive, clinically significant prostate cancer (Gleason grades 8-10). CONCLUSIONS: The mGPS is a strong measure of systemic inflammation, when compared with NLR. Prostate cancer patients with a raised mGPS had significantly higher risk of death for overall as well high-grade disease. Inflammation-based prognostic scores predict outcome in patients with prostate cancer and should be added to their routine clinical assessment.

The cataract national data set electronic multi-centre audit of 55,567 operations: case-mix adjusted surgeon's outcomes for posterior capsule rupture.

AIMS: To develop a methodology for case-mix adjustment of surgical outcomes for individual cataract surgeons using electronically collected multi-centre data conforming to the cataract national data set (CND). METHODS: Routinely collected anonymised data were remotely extracted from electronic patient record (EPR) systems in 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were carried out to risk adjust outcomes for posterior capsule rupture rates for individual surgeons, with stratification by surgical grade. RESULTS: A total of 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). In all, 283 surgeons contributed data on >25 cases, providing 54,319 operations suitable for detailed analysis. Case-mix adjusted results of individual surgeons are presented as funnel plots for all surgeons together, and separately for three different grades of surgeon. Plots include 95 and 99.8% confidence limits around the case-mix adjusted outcomes for detection of surgical outliers. CONCLUSIONS: Routinely collected electronic data conforming to the CND provides sufficient detail for case-mix adjustment of cataract surgical outcomes. The validation of these risk indicators should be carried out using fresh data to confirm the validity of the risk model. Once validated this model should provide an equitable approach for peer-to-peer comparisons in the context of revalidation.

Intraoperative complications of cataract surgery in the very old.

AIM: To identify whether the risk of an intraoperative complication of phakoemulsification cataract surgery increases with age. METHODS: 1441 consecutive patients undergoing phakoemulsification cataract surgery were assessed preoperatively, and data on the occurrence of intraoperative complications were collected prospectively. Data were entered into a computerised database, and logistic regression was used to examine evidence of an association between age and the risk of an intraoperative complication. In addition, the rates of intraoperative complications were compared between patients > or =88 years and those <88 years, and between patients > or =96 years and those <96 years. RESULTS: No significant association was found between age and the risk of an intraoperative complication. The authors found little evidence that patients > or =88 years were at a greater risk of an intraoperative complication than those <88 years, or that those > or =96 years are at increased risk; however, numbers were small. CONCLUSIONS: These results suggest that age alone is not a major risk factor for any intraoperative complications occurring during phakoemulsification cataract surgery. This has implications not just for tailoring the risk of complications occurring to individual patients but also for meaningful comparisons between national complication rates and those of individual surgeons, and better selection of cases suitable for instruction.

Health care workers' ability and willingness to report to duty during catastrophic disasters.

Catastrophic disasters create surge capacity needs for health care systems. This is especially true in the urban setting because the high population density and reliance on complex urban infrastructures (e.g., mass transit systems and high rise buildings) could adversely affect the ability to meet surge capacity needs. To better understand responsiveness in this setting, we conducted a survey of health care workers (HCWs) (N =6,428) from 47 health care facilities in New York City and the surrounding metropolitan region to determine their ability and willingness to report to work during various catastrophic events. A range of facility types and sizes were represented in the sample. Results indicate that HCWs were most able to report to work for a mass casualty incident (MCI) (83%), environmental disaster (81%), and chemical event (71%) and least able to report during a smallpox epidemic (69%), radiological event (64%), sudden acute respiratory distress syndrome (SARS) outbreak (64%), or severe snow storm (49%). In terms of willingness, HCWs were most willing to report during a snow storm (80%), MCI (86%), and environmental disaster (84%) and least willing during a SARS outbreak (48%), radiological event (57%), smallpox epidemic (61%), and chemical event (68%). Barriers to ability included transportation problems, child care, eldercare, and pet care obligations. Barriers to willingness included fear and concern for family and self and personal health problems. The findings were consistent for all types of facilities. Importantly, many of the barriers identified are amenable to interventions.

Health and safety hazards associated with subways: a review.

Subway systems are key components in mass transportation networks worldwide, providing rapid and affordable transportation to urban communities in 58 different countries. The benefits afforded by subway transit are numerous and mainly derived from the reduction in automobile use, thereby limiting environmental and health hazards associated with exhaust-air emissions. Additionally, by limiting congestion and providing vital transportation links within a city, subways also improve the overall quality of life of urban communities. However, to best maximize the positive impact on the urban environment, subway systems need to provide a safe and healthy environment for both passengers and subway transit workers. Periodically, safety concerns are raised, most recently in relation to the vulnerability of subways to terrorist attacks. To examine this issue more carefully, we conducted a structured review of the literature to identify and characterize potential health and safety hazards associated with subways. A secondary goal was to identify various risk management strategies designed to minimize the risk of these hazards. This information may be helpful to urban communities, urban planners, public health specialists, and others interested in subway safety.