'Original antigenic sin', T cell memory, and malaria sporozoite immunity: an hypothesis for immune evasion

Prior to any exposure to malaria, most adults have T cells specific for malaria parasites and various malaria proteins. The protein for which this has been shown more than any other is the circumsporozoite protein (CSP) of Plasmo-dium falciparum. These T cells can be present in high frequency and appear to have arisen through exposure to other (non-malaria) organisms. Although T cells are thought to provide protection against sporozoites, these T cells specific for cross-reactive organisms are clearly unable to protect against malaria, and may be preferentially expanded following exposure to malaria sporozoites. Thus, cross-reactive organisms have the potential to skew the repertoire of sporozoite-induced T cells and affect the induction of protective immunity. This is analogous to the concept of 'original antigenic sin' whereby prior exposure to one strain of influenza virus was shown to be able to divert the antibody response to a second challenging strain to focus on the shared (cross-reactive) epitopes.     

Electronic Medical Records and Electronic Health Records: Overview for Nurse Practitioners

Electronic medical records (EMRs) and electronic health records (EHRs) have become essential systems by which nurse practitioners (NPs) communicate vital patient information to other members of the health care team as well as to patients. In this article we examine the important distinctions between EMRs and EHRs; review the genesis of these types of records; summarize applicable provisions of the Health Insurance Portability and Accountability Act from a recent legal case centered around NP utilization of EMRs and EHRs; address open patient access to medical information; and examine threats to security. Suggestions are offered on ways in which NPs can safeguard confidential patient information.     

Using Natural Language Processing on Electronic Health Records to Enhance Detection and Prediction of Psychosis Risk

BackgroundUsing novel data mining methods such as natural language processing (NLP) on electronic health records (EHRs) for screening and detecting individuals at risk for psychosis. MethodThe study included all patients receiving a first index diagnosis of nonorganic and nonpsychotic mental disorder within the South London and Maudsley (SLaM) NHS Foundation Trust between January 1, 2008, and July 28, 2018. Least Absolute Shrinkage and Selection Operator (LASSO)-regularized Cox regression was used to refine and externally validate a refined version of a five-item individualized, transdiagnostic, clinically based risk calculator previously developed (Harrell’s C = 0.79) and piloted for implementation. The refined version included 14 additional NLP-predictors: tearfulness, poor appetite, weight loss, insomnia, cannabis, cocaine, guilt, irritability, delusions, hopelessness, disturbed sleep, poor insight, agitation, and paranoia. ResultsA total of 92 151 patients with a first index diagnosis of nonorganic and nonpsychotic mental disorder within the SLaM Trust were included in the derivation (n = 28 297) or external validation (n = 63 854) data sets. Mean age was 33.6 years, 50.7% were women, and 67.0% were of white race/ethnicity. Mean follow-up was 1590 days. The overall 6-year risk of psychosis in secondary mental health care was 3.4 (95% CI, 3.3–3.6). External validation indicated strong performance on unseen data (Harrell’s C 0.85, 95% CI 0.84–0.86), an increase of 0.06 from the original model. ConclusionsUsing NLP on EHRs can considerably enhance the prognostic accuracy of psychosis risk calculators. This can help identify patients at risk of psychosis who require assessment and specialized care, facilitating earlier detection and potentially improving patient outcomes.     

Attitudes of Jewish and Bedouin responders toward family physicians’ use of electronic medical records during the medical encounter

Objective

Culture is known to impact expectations from medical treatments. The effects of cultural differences on attitudes toward Electronic Medical Records (EMR) have not been investigated. We compared the attitudes of Jewish and Bedouin responders toward EMR's use by family physicians during the medical encounter, and examined the contribution of background variables to these attitudes.

Methods

86 Jewish and 89 Bedouin visitors of patients in a regional Israeli University Medical Center responded to a self-reporting questionnaire with Hebrew and Arabic versions.

Results

T-tests and a linear regression analysis found that culture did not predict attitudes. Respondents’ self-reported health status, Internet and e-mail use, and estimates of their physician's typing speed explained a total of 18.6% of the variance in attitudes (p < 0.001).

Conclusion

Bedouins respondents’ attitudes toward EMR use were better than expected and similar to those of their Jewish counterparts. The most significant factor influencing respondents’ attitudes was the physician's typing speed.

Practice implications

(1) Further studies should consider the possible impact of cultural differences between the family physician and the healthcare client on attitudes. (2) Interventions to improve physicians’ skill in operating EMRs and typing will potentially have a positive impact on patients’ satisfaction with physicians’ EMR use.     

Adverse events recorded in English primary care: observational study using the General Practice Research Database

Background

More accurate and recent estimates of adverse events in primary care are necessary to assign resources for improvement of patient safety, while predictors must be identified to ameliorate patient risk.

Aim

To determine the incidence of recorded iatrogenic harm in general practice and identify risk factors for these adverse events.

Design and setting

Cross-sectional sample of 74 763 patients at 457 English general practices between 1 January 1999 and 31 December 2008, obtained from the General Practice Research Database.

Method

Patient age at study entry, sex, ethnicity, deprivation, practice region, duration registered at practice, continuity of care, comorbidities, and health service use were extracted from the data. Adverse events were defined by Read Codes for complications of care (Chapters S, T, and U). Crude and adjusted analyses were performed by Poisson regression, using generalised estimating equations.

Results

The incidence was 6.0 adverse events per 1000 person-years (95% confidence interval [CI] = 5.74 to 6.27), equivalent to eight adverse events per 10 000 consultations (n = 2 540 877). After adjustment, patients aged 65–84 years (risk ratio [RR] = 5.62, 95% CI = 4.58 to 6.91; P<0.001), with the most consultations (RR = 2.14, 95% CI = 1.60 to 2.86; P<0.001), five or more emergency admissions (RR = 2.08, 95% CI = 1.66 to 2.60; P<0.001), or the most diseases according to expanded diagnosis clusters (RR = 8.46, 95% CI = 5.68 to 12.6; P<0.001) were at greater risk of adverse events. Patients registered at their practice for the longest periods of time were less at risk of an adverse event (RR = 0.40, 95% CI = 0.35 to 0.47; P<0.001).

Conclusion

The low incidence of recorded adverse events is comparable with other studies. Temporal sequencing of risk factors and case ascertainment would benefit from data triangulation. Future studies may explore whether first adverse events predict future incidents.     

The trends in EMR and CPOE adoption in Japan under the national strategy

PurposeWe evaluate the status of health information system (HIS) adoption (In this paper, “HIS” means electronic medical record system (EMR) and computerized provider order entry system (CPOE)). We also evaluate the affect of the policies of Japanese government.MethodsThe status of HIS adoption in Japan from 2002 to 2011 was investigated using reports from complete surveys of all medical institutions conducted by the Ministry of Health, Labour and Welfare (MHLW). HIS-related budgets invested by the Japanese government from 2000 to 2008 were surveyed mainly using literatures and administrative documents of the Japanese government (MHLW and Ministry of Economy, Trade and Industry).ResultsThe rates of HIS adoption in Japan in 2011 were: 20.9% for the rate of EMR adoption in clinics, 20.1% for the rate of EMR adoption and 36.6% for the rate of CPOE adoption in hospitals. In hospitals, the rate of EMR and CPOE adoption were 51.5% and 78.6% in 822 large hospitals (400 or more beds), 27.3% and 52.1% in 1832 medium hospitals (200–399 beds), and 13.5% and 26.0% in 5951 small hospitals (less than 200 beds), respectively. Japan has a large number of medical institutions (99,547 clinics and 8605 hospitals) with a low rate of EMR adoption in clinics and a high rate of HIS adoption in hospitals. The national budget to expand HIS use was implemented for medium and large hospitals mainly. The policy target of New IT Reform Strategy was not achieved.ConclusionThe rate of HIS adoption in Japanese medium and large hospitals is high compared to small hospitals and clinics, and this is attributable to the fact that the Japanese government placed the target for HIS adoption on key hospitals with a large number of beds and concentrated budget investment in those hospitals. Besides, legal approval of EMR and the introduction of Diagnostic Procedure Combination system facilitated EMR adoption. There is less financial support for small hospitals than medium and large hospitals. The low rate of EMR adoption in clinics stems from the facts that there was little subsidies or incentives in the national remuneration for medical services, lack of cooperation from medical associations, and a failed attempt to mandate computerization of medical accounting (medical billing). Giving financial incentives is an effective means of raising EMR adoption rate. For wide usage of HIS, more financial support and incentive may be necessary for small hospitals and clinics.     

Online Access to Doctors' Notes: Patient Concerns About Privacy

Background

Offering patients online access to medical records, including doctors’ visit notes, holds considerable potential to improve care. However, patients may worry about loss of privacy when accessing personal health information through Internet-based patient portals. The OpenNotes study provided patients at three US health care institutions with online access to their primary care doctors’ notes and then collected survey data about their experiences, including their concerns about privacy before and after participation in the intervention.

Objective

To identify patients’ attitudes toward privacy when given electronic access to their medical records, including visit notes.

Methods

The design used a nested cohort study of patients surveyed at baseline and after a 1-year period during which they were invited to read their visit notes through secure patient portals. Participants consisted of 3874 primary care patients from Beth Israel Deaconess Medical Center (Boston, MA), Geisinger Health System (Danville, PA), and Harborview Medical Center (Seattle, WA) who completed surveys before and after the OpenNotes intervention. The measures were patient-reported levels of concern regarding privacy associated with online access to visit notes.

Results

32.91% of patients (1275/3874 respondents) reported concerns about privacy at baseline versus 36.63% (1419/3874 respondents) post-intervention. Baseline concerns were associated with non-white race/ethnicity and lower confidence in communicating with doctors, but were not associated with choosing to read notes or desire for continued online access post-intervention (nearly all patients with notes available chose to read them and wanted continued access). While the level of concern among most participants did not change during the intervention, 15.54% (602/3874 respondents, excluding participants who responded “don’t know”) reported more concern post-intervention, and 12.73% (493/3874 respondents, excluding participants who responded “don’t know”) reported less concern.

Conclusions

When considering online access to visit notes, approximately one-third of patients had concerns about privacy at baseline and post-intervention. These perceptions did not deter participants from accessing their notes, suggesting that the benefits of online access to medical records may outweigh patients’ perceived risks to privacy.     

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives

Background  Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. Objectives  The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. Methods  We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. Results  Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1–38) years and had used an electronic medical record for 7.0 (1–20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers'' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). Conclusion  Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.     

Why Patients Visit Dentists – A Study in all World Health Organization Regions

ObjectiveThe dimensions of oral health–related quality of life (OHRQoL) Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact are the major areas where patients are impacted by oral diseases and dental interventions. The aim of this study was to evaluate whether dental patients' reasons to visit the dentist fit the 4 OHRQoL dimensions.MethodsDentists (N = 1580) from 32 countries participated in a web-based survey. For their patients with current oral health problems, dentists were asked whether these problems were related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact or whether they do not fit the aforementioned 4 categories. Dentists were also asked about their patients who intended to prevent future oral health problems. For both patient groups, the proportions of oral health problems falling into the 4 OHRQoL dimensions were calculated.ResultsFor every 100 dental patients with current oral health problems, 96 had problems related to teeth, mouth, and jaws' function, pain, appearance, or psychosocial impact. For every 100 dental patients who wanted to prevent future oral health problems, 92 wanted to prevent problems related to these 4 OHRQoL dimensions. Both numbers increased to at least 98 of 100 patients when experts analyzed dentists' explanations of why some oral health problems would not fit the four dimension. For the remaining 2 of 100 patients, none of the dentist-provided explanations suggested evidence against the OHRQoL dimensions as the concepts that capture dental patients' suffering.ConclusionOral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact capture dental patients' oral health problems worldwide. These 4 OHRQoL dimensions offer a psychometrically sound and practical framework for patient care and research, identifying what is important to dental patients.