Personalizing Medication Recommendation with a Graph-Based Approach

The broad adoption of electronic health records (EHRs) has led to vast amounts of data being accumulated on a patient’s history, diagnosis, prescriptions, and lab tests. Advances in recommender technologies have the potential to utilize this information to help doctors personalize the prescribed medications. However, existing medication recommendation systems have yet to make use of all these information sources in a seamless manner, and they do not provide a justification on why a particular medication is recommended. In this work, we design a two-stage personalized medication recommender system called PREMIER that incorporates information from the EHR. We utilize the various weights in the system to compute the contributions from the information sources for the recommended medications. Our system models the drug interaction from an external drug database and the drug co-occurrence from the EHR as graphs. Experiment results on MIMIC-III and a proprietary outpatient dataset show that PREMIER outperforms state-of-the-art medication recommendation systems while achieving the best tradeoff between accuracy and drug-drug interaction. Case studies demonstrate that the justifications provided by PREMIER are appropriate and aligned to clinical practices.

A Case of Unrelenting Facial Swelling

Melkersson-Rosenthal syndrome (MRS) is an uncommon disorder with presenting symptoms that typically involve the face and orofacial structures. It is a difficult diagnosis to make, as it may present with a protracted course of seemingly unrelated dermatological, ocular, and neurological findings. This case report reviews the presentation, workup, and diagnosis of a 75-year-old woman who presented with orofacial swelling, facial palsy, and tongue fissuring that had intermittently recurred over 10 years without a unifying diagnosis. Extensive medical history, photography, laboratory workup, and radiographic imaging were performed to identify the diagnosis of MRS in this patient. Our case highlights the challenge and importance of critically evaluating and consolidating a patient’s history of their present illness, physical examination, and ancillary testing to successfully establish a unifying diagnosis, especially when the diagnosis is relatively rare and diverse in its range of affected populations and symptomatology.

Pseudopterygium in a Rabbit - Treatment with Tracolinus

Background: Pseudopterygium, also known as aberrant conjunctival growth, is poorly described in the literature, although it is known that this abnormality is uncommon and affects dwarf rabbits and their crossbreeds. The etiology of this disease is unknown, but there are hypotheses that the conjunctival growth cause may have its origins in immunological factors, inflammation, traumatic conditions, or cartilage dysplasias. Thus, this study reports the treatment efficacy applied in a rabbit, through the continuous use of tracolimus eye drops, after surgical procedure of conjunctival fold resection, as a way of controlling the pseudopterygium in rabbits.Case: This case report discusses the positive results from the surgical and therapeutic conduct of a clinical case attended by the Ophthalmology and Microsurgical Veterinary Service at the Hospital Veterinário Universitário (HVU) of the UFSM. The patient was a male rabbit, sterilized cunicle, approximately 2-year-old, crossed with a dwarf rabbit. The owner's main complaint was the change in the aspect of the left eye, with progressive worsening in the previous four weeks. In the ophthalmological examination, the animal did not present impaired vision or discomfort, however, a vascularized pink membrane was noted, which consisted of a fold of the bulbar conjunctiva, that grew centripetally and covered 90% of the cornea in 360 degrees. The diagnosis was confirmed through visual inspection and the patient's history. The eye alteration had a characteristic aspect, described as proliferation of the bulbar conjunctiva over the cornea, in a centripetal manner and without signs of inflammation. In addition, other ophthalmological alterations were ruled out during the patient's physical and specific examination. The patient was referred for anesthetic evaluation and, in addition, pre-surgical blood tests were performed, which were normal, according to the expected ranges for the species. Subsequently, the animal was submitted to surgical treatment, which consisted of dividing the exuberant conjunctiva, followed by three radial incisions in equal portions. Next, the conjunctival fold was completely incised to the edge of the limbus, without the need of sutures. Anterior lamellar keratectomy was performed on the portion where the membrane was attached to the cornea. For home care, tobramycin-based eye drops (QID, for 7 days) and 0.02% aqueous tacrolimus eye drops (BID - continuous use) were prescribed. The animal was reevaluated 7, 14, 30, 60, 120 and 180 days after surgical correction, and no recurrence of pseudopterygium was observed during the follow-up period. The prognosis of patients with pseudopterygium is reserved, as it is known that the disease may recur after surgical treatment. Therefore, the continuous use of the chosen immunomodulating eye drops was recommended as well as periodic follow-up of the patient.Discussion: In the current study, it was not possible to increase knowledge regarding about the pseudopterygium etiology. Although the condition is not serious, it can cause partial impairment of vision and chronic discomfort. However, the vision field described in the rabbit in this current case remained unchanged, in accordance with other cases described in the literature. Furthermore, no signs of patient discomfort were detected. Some surgical techniques described in the literature for correction of pseudopterygium, shows membrane’s growth recurrence. The use of immunomodulatory drugs is suggested for relapses controlling. In this study, the tracolimus eye drops efficacy was tested, and presented good results in the patient's evaluations for a long period after surgery. The use of immunomodulators is an option for adjuvant topical treatment for controlling pseudopterygium growth, which, associated with corrective surgical treatment, has shown positive results.Keywords: conjunctiva, aberrant, immunomodulator, treatment, bunny.Título: Pseudopterígio em coelho - tratamento com tracolimusDescritores: conjuntiva, aberrante, imunomodulador, tratamento, coelho.

Understanding Opioid Prescribing Practices of Resident Physicians

Background To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. Methods An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher’s exact test assessed differences in prescribing practices between specialties. Results Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient’s history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills ( P < .001). Discussion The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

In women with incontinence, the need for pressure-flow study before surgery and abnormalities in the voiding phase. An up-to-date comment on the available problem accompanied by literature

Objective: To investigate the differences between urodynamic findings and history in women with urinary incontinence before surgery and clarify the need for preoperative pressure-flow studies. Materials and methods: The medical records of 1018 women who underwent urodynamic examination for urinary incontinence between 2010 and 2015 were evaluated retrospectively. Stress (n = 442), urge (n = 334) and mixed (n = 242) were classified as type urinary incontinence according to urodynamics. The voiding phase findings of the patients were examined. Results: The mean age of the patients was 47.85 ± 0.27 years. 18.4% of patients (n = 187) had voiding phase problems. Furthermore, this condition was seen in the most urge incontinence type urinary incontinence (35%). There was a statistically significant difference between the groups' voiding phase findings (p < 0.0001). The relationship between the patient's history and international consultation on incontinence questionnaire form scoring (ICIQ) and the urodynamics results showed no excellent correlation. Conclusions: Voiding phase abnormalities are not uncommon in patients with urinary incontinence. They should be considered in the evaluation of patients. Voiding phase findings may show significant differences between urodynamic data and history. Besides, the data obtained with the questionnaire forms were significantly different from the findings obtained by urodynamics. Consequently, urodynamics may change pre-operative clinical decision.

A case report of lymphoepithelioma-like carcinoma in an adolescent

Here we report a case of EBV-positive lymphoepithelioma-like carcinoma of the abdominal and retroperitoneal lymph nodes in a 17-year-old girl. This case is of special interest because of the rarity of the diagnosis (especially in adolescents), the unusual location of the tumor, the patient’s history of infections and autoimmune diseases (autoimmune hepatitis, Crohn’s disease) and the absence of standard treatment guidelines for this tumor. The patient and her legal representatives gave their consent to the use of the patient’s data, including photographs, for research purposes and in publications.

Diagnosis and Treatment of Elderly and Senile Chronic Constipation: an Expert Consensus

Aim. An appraisal of practitioners with chronic constipation management details in older and senile adults.Key points. Chronic constipation is a common issue in geriatrics. Aside to age-related physiological bowel disfunction, a higher constipation incidence is conditioned by declined physical activity and frailty, polypharmacy and a series of secondary constipation-developing chronic states and diseases. Chronic constipation is associated with a higher risk of cardiovascular disease and complications, impaired general perception of health and pain, growing alarm and depression, and reduced quality of life. The treatment tactics in chronic constipation is cause-conditioned and should account for the patient’s history and therapy line, overall clinical condition, cognitive status and functional activity level. An essential baseline aspect of constipation management is apprising the patient and his family of the underlying factors and methods for non-drug and drug correction. An higher-fibre diet is recommended as first measure, with osmotic laxatives added and titrated to clinical response if none observed towards the non-drug and high-fibre regimens. Stimulant laxatives and prokinetics should be recommended in patients reluctant to fibre supplements and osmotic laxatives. Subsidiary correction includes biofeedback, transanal irrigation, acupuncture, foot reflexology and percutaneous tibial nerve stimulation.Conclusion. Elderly and senile chronic constipation is a prevalent multifactorial state requiring an efficient management via assessment and correction of total risk factors and consistent use of non-medication and drug therapies.

Study on Septal Correction: Review of Literature and Clinical Findings

Septal reconstruction has many needs and usages. Nowadays, people are very concerned about looking and would like to correct them. Septal reconstruction has been immensely used in the field of cosmetics. A successful septoplasty would lead us to know about the pathology of the septum by which we can avoid further complications. It would be further significant in nasal obstruction or difficulty in breathing. Deviation of the nasal septum can also be corrected by septal reconstruction by various techniques used for septoplasty. Complete septal reconstruction is the best method for extreme S-shaped and wave-like deviations or multiple fractures. The septoplasty is performed endonasal for caudal septal deviation. Traction sutures to rectify the caudal septum deviation is another type of surgery. Septoplasty usually opens the way for all other rhinoplasty procedures, as a straight, stable septum reflects the attractiveness and functionality of the nose. The patient's history and the surgeon's expertise play a favorable outcome. In conjunction with other nose procedures, such as cosmetic rhinoplasty and endoscopic sinus surgery, Septoplasty is frequently done to alleviate nasal airway obstruction or headaches induced by rhinology irritation produced by touch. Endoscopic septoplasty requires the same amount of time and delivers equal, if not better, results than previous procedures. Visualization is vastly improved by endoscopic technology. Isolated deviation, spurs, perforations, and contact sites are examples of distinct septal disorders that can be treated individually using this procedure. In this review article, the importance of traction sutures is mentioned. The article gives us an idea about Septoplasty and how it can be achieved, its complications, risk factors, and a few postoperative points.

Displacement and Arrest of Root Formation in a Permanent Maxillary Central Incisor Subsequent to Trauma to the Primary Predecessor: A Case Report

The present report aimed to explore the case of an 8-year-old patient with chief complaint of the lack of eruption of the maxillary right permanent central incisor, referring to the Department of Pediatric Dentistry, Faculty of Dentistry, Hamadan University of Medical Sciences. The corresponding tooth on the contralateral side had fully erupted. The patient’s history revealed that the predecessor deciduous tooth had sustained a trauma, resulting in the partial intrusion of the tooth into the alveolar bone, that is, the relative intrusion of the deciduous central incisor. CBCT examinations were ordered for further evaluation, which showed the upward displacement of the permanent tooth bud in the alveolar bone as a result of the trauma, adhering to the floor of the nasal cavity. Therefore, root formation was halted, making the tooth embedded.

A Case of Trimethoprim-Sulfamethoxazole-Induced Aseptic Meningitis Masquerading as Septic Shock

ABSTRACT Trimethoprim-sulfamethoxazole-induced aseptic meningitis (TSIAM) is a rare adverse reaction to a commonly prescribed antibiotic. We describe a case of severe TSIAM which resembled septic shock. A 30-year-old male with relapsed Hodgkin’s lymphoma 25 days status post autologous stem cell transplant presented to our clinic for evaluation of trimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity. After review of patient’s history and records, we had a low suspicion for a TMP-SMX adverse reaction and conducted an oral challenge to one 160 mg/800 mg tab of TMP-SMX. Four hours later, the patient developed vomiting, lightheadedness, and disorientation with progression to rigors, fever, tachycardia, and hypotension. He was admitted for fluid resuscitation and broad-spectrum antibiotic coverage for neutropenic fever and possible septic shock. A lumbar puncture performed due to complaints of headache, photophobia, and neck pain showed 375 white blood cells/µL with 73% neutrophil predominance, normal glucose (75 mg/dL), and elevated protein (101 mg/dL); additional cerebrospinal fluid (CSF) studies were negative for infectious etiologies. Fever and headache resolved by hospital day 4, at which time patient was discharged home. We believe this case represents TSIAM given the characteristic timing of symptom onset, CSF findings, and timing of symptom resolution without other clear etiology found on extensive infectious evaluation. It is important for allergists to recognize TSIAM, including its potential presentation as shock, in order to appropriately diagnose and counsel patients who seek evaluation for TMP-SMX adverse reactions.