Terry J. Hannan

An electronic medical record system for ambulatory care of HIV-infected patients in Kenya

Administering and monitoring therapy is crucial to the battle against HIV/AIDS in sub-Saharan Africa. Electronic medical records (EMRs) can aid in documenting care, monitoring drug adherence and response to therapy, and providing data for quality improvement and research. Faculty at Moi University in Kenya and Indiana and University in the USA opened adult and pediatric HIV clinics in a national referral hospital, a district hospital, and six rural health centers in western Kenya using a newly developed EMR to support comprehensive outpatient HIV/AIDS care. Demographic, clinical, and HIV risk data, diagnostic test results, and treatment information are recorded on paper encounter forms and hand-entered into a central database that prints summary flowsheets and reminders for appropriate testing and treatment. There are separate modules for monitoring the Antenatal Clinic and Pharmacy. The EMR was designed with input from clinicians who understand the local community and constraints of providing care in resource poor settings. To date, the EMR contains more than 30,000 visit records for more than 4000 patients, almost half taking antiretroviral drugs. We describe the development and structure of this EMR and plans for future development that include wireless connections, tablet computers, and migration to a Web-based platform.

The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya

Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.

Variation in health care—the roles of the electronic medical record

Variation in the use of clinical resources, outcomes, costs, access to health care and quality is a well recognized, ever present feature of health care. It is a phenomenon that affects all sectors of the health care delivery process and is important to clinicians, administrators and patients. As a phenomenon variation can be appropriate or inappropriate and the elimination of inappropriate variation is a fundamental principal behind continuous quality improvement in health care. The primary tools for the management of variation exists within the electronic medical record (EMR). The EMR utilizes the existing and evolving information storage technologies (data repositories) and information management tools (applications), to integrate the elements within this long-term data storage. Through this integration the EMR systems are able to provide knowledge representation in differing formats to the decision-makers and this will facilitate more accurate and appropriate decision-making with subsequent improvements in health care delivery.

Detecting adverse drug reactions to improve patient outcomes

Adverse drug reactions and inappropriate administration of medications account for poor outcomes for patients. They place patients in life-threatening situations, lead to increased health care costs, extend length of stay in hospitals, as well as increasing litigation. This paper will highlight the incidence of adverse drug events (ADE) in health care and show the low rate of detection within conventional medical records. I will also show how electronic medical records (EMR) improve detection of ADE, enhance clinician compliance to their management, improve patient outcomes, and reduce health care costs.

Successful Treatment with Thrombopoietin Receptor Agonist in Avoiding Splenectomy for Patients with Chronic Refractory Immune Thrombocytopenia

Background Chronic immune thrombocytopenia (ITP) is a condition associated with significant morbidity; however the management options are often unsatisfactory with a portion of patients exhibiting a refractory-relapsing disease path despite various lines of treatment including splenectomy. As a thrombopoietin receptor agonist, eltrombopag (GlaxoSmithKline, Australia) provides a novel treatment option for patients with refractory disease. We describe the outcomes of four patients with chronic ITP, who were treated with eltrombopag as a single agent. Methods Four Caucasian patients with chronic refractory ITP (2 males; 2 females) were enrolled in this study with a mean age of 48 years (range, 39–59). All patients were non-splenectomised and were refractory to several lines of treatment including steroids, intravenous immunoglobulin, vincristine, and azathioprine, one patient has also received rituximab (a monoclonal antibody that binds the CD20 antigen expressed by B-lymphocytes). All patients were treated with oral eltrombopag (50–75 mg) for a median period of 12 months (range, 9–16). Results After a median follow up of 20 months (range, 11–34), platelet counts recovered to normal levels in two patients. One recovered a normal platelet count after 13 months, the other 34 months of completion of treatment with eltrombopag. No additional immune suppressive therapy was required. The other two patients also discontinued eltrombopag at 27 and 11 months after achievement of satisfactory platelet counts above 30/nL without any bleeding complications. Other forms of immune therapy were also ceased in these two cases. None of the four patients required splenectomy. Conclusion The clinical outcomes in this small cohort of patients suggests that eltrombopag may have a role to play in the long term control of chronic ITP whilst avoiding splenectomy and long term immunosuppressive therapy. The beneficial outcomes in our patients led to a sustained elevation in platelets with no adverse effects noted when used for relatively longer periods than previously reported. It is worth noting that spontaneous remission does occur with ITP and is the most likely cause for the favourable outcome with eltrombopag therapy. However, if eltrombopag is able to reduce the need for splenectomy in patients with chronic ITP then a distinct quality of care outcome can be achieved by avoiding the recognised short- and long-term complications of splenectomy. Randomised controlled trials with long-term follow up are warranted.

Effect of immunoglobulin therapy on the rate of infections in multiple myeloma patients undergoing autologous stem cell transplantation or treated with immunomodulatory agents.

Multiple myeloma (MM) is associated with a significant risk of infection due to immune dysfunction. Infections are a major cause of morbidity and mortality in MM patients. There are few data available regarding the prevalence of infection in MM patients, especially in conjunction with newer generations of immunomodulatory drugs (thalidomide, bortezomib, lenalidomide) or post autologous stem cell transplantation (ASCT). Intravenous immunoglobulin (IVIG) has been used successfully to reduce infection rates in the stable phase of MM, with limited data in other stages. We retrospectively analyzed 47 patients with MM from March 2006 to June 2009 at our institution. All patients received thalidomide and steroid therapy for at least 6 months. Nine patients received bortezomib and 11 lenalidomide subsequent to thalidomide, because of disease progression, and 22 patients underwent ASCT. The median age was 64 years (range 37–86), with a female–to-male ratio of 18:29. The median residual-serum IgG-level at time of infection was 3.2 g/L, IgA 0.3 g/L and IgM 0.2 g/L. Most patients suffered from recurrent moderate to severe bacterial infections, including the ASCT group. Fifteen patients suffered from different degrees of viral infections. All patients except 3 received IVIG therapy with a significant decline of the rate of infection thereafter (p<001). Our analysis shows that patients with MM treated with the new immunomodulatory drugs in conjunction with steroids are at significant increased risk of infection. Employing IVIG therapy appears to be an effective strategy to prevent infection in this cohort of patients. Further studies to confirm these findings are warranted.

Are doctors the structural weakness in the e‐health building?

Progressive evaluations by the Organization for Economic Co‐operation and Development (OECD) demonstrate that health care is now or becoming unaffordable. This means nations must change the way they manage health care. The costly nature of health care in most nations, as a percentage of Gross Domestic Product (GDP) seems independent of the national funding models. Increasing evidence is demonstrating that the lack of involvement by clinicians (doctors, nurses, pharmacists, ancillary care and patients) in e‐health projects is a major factor for the costly failures of many of these projects.

Catatonia Associated with Temazepam Withdrawal

Catatonia is manifested by any of the following features: motoric immobility or excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia, or echopraxia [1]. Catatonia may be associated with affective disorders, schizophrenia, and a variety of neurological and general medical conditions [2], including benzodiazepine withdrawal [3,4]. We report a case of catatonia associated with acute temazepam withdrawal, the fi rst such case to be reported to our knowledge. A 73 year old woman with no prior history of psychiatric illness was admitted to a general hospital with an infective exacerbation of her chronic obstructive pulmonary disease. On the fourth day of her admission she was discovered to be in an acute catatonic state: mute and immobile in her bed, lying in the posture of an entombed soldier with her arms crossed over her chest and her eyes squeezed shut. There was no deterioration in her physical parameters. The patient also experienced periods of extreme agitation, walking with a stooped posture and a shuffl ing gait, and remained mostly mute with occasional incomprehensible speech or echolalia. On reviewing potential causes of her catatonic symptoms, it was noted that she had been taking temazepam regularly at 40 mg a day for the last 40 years, and that her dose had been reduced to 20 mg on admission. It had not been administered 24 hours before the deterioration and the patient had subsequently refused all oral medications. As there were no other likely causes of her deterioration, a preliminary diagnosis of catatonia due to benzodiazepine withdrawal was made. An initial dose of 2.5 mg of midazolam was given intramuscularly as the patient continued to refuse oral medication. This resulted in a rapid improvement and the oral temazepam was re-initiated, with a full recovery to her premorbid coherent state. She did not experience any return of the symptoms. We believe this patient had a rare adverse reaction of catatonia related to the sudden suspension of her usual benzodiazepine medication. The patient had multiple risk factors for severe benzodiazepine withdrawal: prolonged, high dose usage of a short acting benzodiazepine [5], as well as being elderly and medically unwell. Interestingly, benzodiazepines are commonly used in the management of catatonia [2]. Benzodiazepines are commonly prescribed in Australia, particularly in the elderly and those with a chronic medical condition [6]. Many of these patients do not appear to have an anxiety or affective disorder. With the increasing documentation of the adverse effects of the long term use of benzodiazepines in the elderly, extreme care needs to be taken in the use of these medications and how they may be withdrawn when considered unnecessary [5]. In general, gradual reduction of the patient ’ s dose is recommended in an ambulatory setting, with the agreement of both the patient and their treating doctor [5], with psychological support for emergent symptoms of insomnia and anxiety.

Venous thromboembolism in medical patients during hospitalisation and 3 months after hospitalisation: a prospective observational study

Objectives This study was conducted to assess the incidence and risk factors for venous thromboembolism (VTE) in a cohort of medical patients both during the period of hospitalisation and following discharge. Design This was a prospective observational study to document the risk profile and incidence of VTE posthospitalisation among all medical patients admitted to our institution during the trial period. Settings Primary healthcare. Single tertiary referral centre, Tasmania, Australia. Participants A total of 986 patients admitted to the medical ward between January 2012 and September 2012 were included in the study with male to female ratio of 497:489. The mean age of patients was 68 years (range 17–112, SD 16). Results Overall, 54/986 patients (5.5%) had a VTE during the study period. Of these, 40/54 (74.1%) occurred during hospitalisation and 14/54 (25.9%) occurred following discharge. VTE risk factors revealed in multivariate analysis to be associated with a previous diagnosis of VTE (p<0.001, OR=6.63, 95% CI 3.3 to 13.36), the occurrence of surgery within the past 30 days (p<0.001, OR=2.52, 95% CI 1.33 to 4.79) and an admission diagnosis of pulmonary disease (p<0.01, OR 3.61, 95% CI 1.49 to 8.76). Mobility within 24 hours of admission was not associated with an increased risk. There was risk of VTE when the length of stay prolonged (p=0.046, OR=1.01, 95% CI 1.00 to 1.03), however it was not sustained with multivariate modelling. VTE-specific prophylaxis was used in 53% of the studied patients. Anticoagulation including antiplatelet agents were administered in 63% of patients who developed VTE. Conclusions This prospective observational study found that 5.5% of the studied patients developed VTE. Among those, 25.9% (14/54) of patients had a detected VTE posthospitalisation with this risk being increased if there was a history of VTE, recent surgery and pulmonary conditions. Thromboprophylaxis may be worth considering in these cohorts. Further study to confirm these findings are warranted. Trial registration number ACTRN12611001255976.

Extensive venous thrombosis in a healthy young man with a short inferior vena cava syndrome treated successfully with rivaroxaban.

We report a case of an incidental finding of congenital absence of the intrahepatic segment of the inferior vena cava (IVC) complicated by extensive bilateral deep venous thrombosis (DVT) with significant oedema following a long-distance road trip. Initially the patient failed treatment with standard anticoagulation therapy with enoxaparin and warfarin. However, he has responded to the new oral antifactor-Xa anticoagulant (rivaroxaban). Within a few days, rivaroxaban improved the oedema and DVT. The significant features of this case are the unusual presentation, the poor response to initial standard anticoagulation therapy and the beneficial outcomes when managed with the novel new anticoagulant. The patient has continued the new treatment regularly for the last 12 months with good toleration and without side effects. This report presents the findings, management and outcomes in a case of extensive bilateral DVT in a previously healthy young man who was found to have a congenital short IVC.