Electronic health records and support for primary care teamwork

Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges.Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size.Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time.Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges.Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.     

Repeat Transarterial Chemoembolization (TACE) for Progressive Hepatic Carcinoid Metastases Provides Results Similar to First TACE

Background Transarterial chemoemobolization (TACE) is commonly used to treat metastatic carcinoid tumors; however, the management of progressive disease is less clear. We sought to determine if patients with disease progression after TACE would benefit from repeat TACE. Methods The records of 27 patients undergoing repeat TACE for radiologic or symptomatic progression after TACE for metastatic carcinoid were reviewed and compared to 122 undergoing first TACE. Overall and progression-free survivals were estimated by the Kaplan–Meier method. Results Mean disease-free interval after first TACE was 11.8 months. Radiologic response was observed in 61% compared to 82% after first TACE (p = 0.058); hormone response in 64% compared to 80% (p = 0.159); and symptomatic response in 77% compared to 92% (p = 0.053). The complication rate after repeat TACE was lower than after first TACE (p = 0.03). Median overall survival was similar after repeat (28.1 months) and first TACE (33.3 months) (p = 0.53). Progression-free survival was shorter after repeat TACE but not significantly so. No factor examined could predict survival after repeat TACE. Conclusion Repeat TACE for patients with hepatic carcinoid metastases failing first TACE or having evidence of disease progression is safe and offers a viable treatment option. Presented at the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, DC, May, 2007.     

It's all about sex: gender, lung development and lung disease.

Accumulating evidence suggests that gender affects the incidence, susceptibility and severity of several lung diseases. Gender also influences lung development and physiology. Data from both human and animal studies indicate that sex hormones might contribute to disease pathogenesis or serve as protective factors, depending on the disease involved. In this review, the influence of gender and sex hormones on lung development and pathology will be discussed, with specific emphasis on pulmonary fibrosis, asthma and cancer.     

The development of excitatory transmitter amino acid-containing neurons in the rat visual cortex

The excitatory amino acids l-glutamate and l-aspartate are believed to be utilized as neurotransmitters by the pyramidal neurons in the mammalian cerebral cortex. These cells can be recognized early in development, while glutamate might play an important part in the maturation and plasticity of the cortex. Here, we used light and electron microscopic immunocytochemistry to study the time of appearance and maturation of glutamate and aspartate in neurons of the rat visual cortex. Glutamate- and aspartate-immunoreactive cells were first detected in deep cortical layers at postnatal day 3. During the next 3 weeks, labelled neurons were observed progressively in more superficial layers, but did not demonstrate their adult pattern of distribution until postnatal week 4. Electron microscopic analysis showed that glutamate- and aspartate-labelled neurons gradually develop their cytological and synaptic features during the first 4 postnatal weeks, with this process of differentiation originating in the deep cortical layers and progressively extending to the superficial layers. These findings suggest that cortical pyramidal neurons begin to express detectable levels of transmitter glutamate and/or aspartate after they have completed their migration. Their neurochemical differentiation follows an inside-out pattern similar to the pattern described for the genesis and morphological differentiation of this population of cortical neurons.     

Comparative effects on the immune system of methotrexate and trimetrexate

Methotrexate (MTX) is an antimetabolite commonly used in the treatment of neoplastic disease, while trimetrexate (TMQ) is an investigational antifolate which is currently advocated as a potential alternative to MTX. The cytotoxic properties of antifolates to rapidly proliferating cells suggests that the immune system would be a significant and undesirable target for these drugs. We examined the comparative effects of these two chemotherapeutic agents on the murine immune system using in vivo and in vitro methods. Both drugs were potent suppressors of T-dependent antibody formation in vitro as well as in vivo. While TMQ appeared to be more immunosuppressive than MTX following in vitro addition of the drugs, the converse appeared to be true when dosing was performed in vivo. The drug induced suppression of T-dependent antibody formation was dose dependent for both antifolates. Lymphoproliferative studies demonstrated marked suppressive effects on LPS and PHA induced 3H-uridine and 3H-deoxyuridine incorporation following addition of both drugs in vitro suggesting effects on both RNA and thymidylate biosynthesis. Timed addition studies demonstrated a particularly susceptible time period (hours 24-48 after addition of the mitogen LPS) in stimulated lymphocytes with respect to inhibition of 3H-uridine incorporation. Following in vivo administration of either antifolate, natural killer cell activity was significantly decreased with no substantial differences between the two drugs.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recurrent retinal artery obstruction as a presenting symptom of ophthalmic artery aneurysm: a case report

Background: Retinal artery obstruction is an ophthalmic emergency requiring immediate treatment. Recurrent episodes are the result of thromboembolic seeding and necessitate diagnostic efforts to find a possible source for this seeding. The most common sources of such seeding are the valves of the heart and the carotid arteries. Case report: We describe a case of a 25-year-old man who had recurrent episodes of retinal artery obstruction due to embolic spread. Discussion: We suggest the origin of the embolic spread to be a post-traumatic ophthalmic artery aneurysm. The immediate and long-term treatment given to the patient are described, the present case is compared to earlier reports, and the unusual clinical picture and suggested treatment are discussed.     

Comparative analysis of urinary schistosomiasis among primary school children and rural farmers in Obollo–Eke,Enugu State,Nigeria: Implications for control

ObjectiveTo determine the prevalence, sex-age related intensity of urinary schistosomiasis and to compare such parameters among rural school children and rural farmers in selected communities in Obollo-Eke located in Southeast, Nigeria.MethodsA cross-sectional survey involving 1 337 school children and farmers was conducted in Obollo-Eke community between September 2006 and July 2007. Demographic data of subjects was collected using a questionnaire prepared for this purpose. Urine samples were collected and examined for haematuria and ova of Schistosoma haematobium (S. haematobium) using Medi-test Combi 9 and sedimentation technique respectively.ResultsThe prevalence of urinary schistosomiasis based on microscopic examination of the urine sediment for the ova of S. haematobium was 17.5% while the prevalence of haematuria was 15.6%. Infection intensity varied from light to heavy. In general, the prevalence was higher among males (20.8%) than females (14.6%; P>0.05) and was slightly higher among primary school children (18.0%; n=762) than farmers (16.9%; n=575; P>0.05). The age-specific prevalence of schistosomiasis among the study subjects ranged from 8.3% to 21.2% in 0-5 years and 11-15 years age groups respectively.ConclusionsHaematuria and mean egg/10 mL urine (r = 0.95; P<0.01) showed that both procedures are reliable for the diagnosis of the disease and can be used to ascertain the prevalence of the disease in any community. The comparative analysis of urinary bilharziasis among primary school children and rural farmers demonstrated that the infection is moderately high in these two risk population groups at Obollo-Eke. A robust intervention strategy is clearly needed.