FHIRing up OpenMRS: Architecture, Implementation and Real-World Use-Cases in Global Health.

HL7 FHIR was created almost a decade ago and is seeing increasingly wide use in high income settings. Although some initial work was carried out in low and middle income (LMIC) settings there has been little impact until recently. The need for reliable and easy to implement interoperability between health information systems in LMICs is growing with large scale deployments of EHRs, national reporting systems and mHealth applications. The OpenMRS open source EHR has been deployed in more than 44 LMIC with increasing needs for interoperability with other HIS. We describe here the development and deployment of a new FHIR module supporting the latest standards and its use in interoperability with laboratory systems, mHealth applications, pharmacy dispensing system and as a tool for supporting advanced user interface designs. We also show how it facilitates date science projects and deployment of machine leaning based CDSS and precision medicine in LMICs.

Autistic traits at neurodevelopmental assessment for very preterm infants.

Aim The aim of this study was to establish the prevalence of autistic traits at childhood neurodevelopmental assessment in a premature cohort and to assess associated perinatal exposures. Methods An observational retrospective case-control study was conducted in a single tertiary neonatal unit. All infants born weighing =1500 grams and/or =32/40 weeks who attended for neurodevelopmental assessment in 2019 were eligible. Results 96 preterm infants met the inclusion criteria. 22 (23%) in the case group demonstrated clinical features of autism at early childhood assessment. The remaining 74 acted as a control group. In the case group 18 (82%) were male. There was no difference in rate of multiple births between the groups. There was no statistically significant difference in maternal age or indication for delivery. Male phenotype (p=0.003), non-Irish ethnicity (p=0.005), vaginal delivery (p=0.005) and abnormal cranial ultrasound (p=0.009) occurred more frequently in the case group. Use of assistive reproductive technologies occurred less frequently in the case group (p=0.047). In the case group, 10/14 of the composite scores measured on Bayleys-3 at a median (IQR) age of 32 (31-35) months showed statistically significant differences (p<0.003). Discussion Our study strongly supports increasing awareness of the association between prematurity and autism. It highlights the need for targeted neurodevelopmental follow-up to support early detection of autism, allowing for timely intervention. Further investigation in a larger prospective cohort may further delineate the various perinatal risk factors for autism.

Clinical Efficacy of Subgingivally Delivered Punica Granatum Chip and Gel in Management of Chronic Periodontitis Patients.

Background Periodontitis has a multifactorial etiology, and the pathogenic bacteria that reside in the subgingival area are the primary etiologic agent. Objective The study aimed to evaluate the clinical efficacy and benefits of herbal chip and gel made from extracts of Punica granatum as a subgingival adjunct to scaling and root planing (SRP). Method A randomized control clinical trial was conducted on 30 systemically healthy patient's sites having chronic periodontitis, and they were randomly allocated to into three treatment groups followed by Scaling and Root Planing in all patients. Group 1 - Ten patients received Scaling and Root Planing and Punica granatum chip at selected sites. Group 2 - Ten patients received Scaling and Root Planing and punica granatum gel at selected sites. Group 3 - Ten patients with Scaling and Root Planing alone. Clinical parameters were recorded at baseline, 21 days and at 45 days which included plaque index (PI), gingival index (GI), probing pocket depth (PPD) and relative attachment level (RAL). Result Plaque Index and Gingival index showed better reduction in group I compared to group II and group III at 21st day 45th day follow up. Analysing Pocket Probing Depth the intergroup comparison revealed similar results with maximum reduction being seen in group I from baseline to 21 and baseline to 45 days (p < 0.001). On analysing Relative Attachment Loss revealed reduction in all three groups with maximum reduction in group I from baseline to 45 days and reduction in group III was not statistically significant (p < 0.090). Conclusion The study concluded that Punica granatum chip as an adjunct to Scaling and Root Planing was more effective than Punica granatum gel and scaling and root planing alone.

Mining of Indian wheat germplasm collection for adult plant resistance to leaf rust.

Leaf rust (Puccinia triticina Eriks.) is a fungal disease of wheat (Triticum spp.), which causes considerable yield loss. Adult plant resistance (APR) is one of the most sustainable approaches to control leaf rust. In this study, field-testing was carried out across ten different locations, followed by molecular screening, to detect the presence of APR genes, Lr34+, Lr46+, Lr67+ and Lr68 in Indian wheat germplasm. In field screening, 190 wheat accessions were selected from 6,319 accessions based on leaf tip necrosis (LTN), disease severity and the average coefficient of infection. Molecular screening revealed that 73% of the accessions possessed known APR genes either as single or as a combination of two or three genes. The occurrence of increased LTN intensity, decreased leaf rust severity and greater expression of APR genes were more in relatively cooler locations. In 52 lines, although the presence of the APR genes was not detected, it still displayed high levels of resistance. Furthermore, 49 accessions possessing either two or three APR genes were evaluated for stability across locations for grain yield. It emerged that eight accessions had wider adaptability. Resistance based on APR genes, in the background of high yielding cultivars, is expected to provide a high level of race non-specific resistance, which is durable.

Assessment of Clinical Pharmacokinetic Drug-Drug Interaction of Antimalarial Drugs α/ß-Arteether and Sulfadoxine-Pyrimethamine.

Antimalarial drug combination therapy is now being widely used for the treatment of uncomplicated malaria. The objective of the present study was to investigate the effects of coadministration of intramuscular α/ß-arteether (α/ß-AE) and oral sulfadoxine-pyrimethamine (SP) on the pharmacokinetic properties of each drug as a drug-drug interaction study to support the development of a fixed-dose combination therapy. A single-dose, open-label, crossover clinical trial was conducted in healthy adult Indian male volunteers (18 to 45 years, n = 13) who received a single dose of AE or SP or a combination dose of AE and SP. Blood samples were collected up to 21 days postadministration, and concentrations of α-AE, ß-AE, sulfadoxine, and pyrimethamine were determined by using a validated liquid chromatography-tandem mass spectrometry method. Pharmacokinetic parameters were calculated and statistically analyzed to calculate the geometric mean ratio and confidence interval. Following single-dose coadministration of intramuscular AE and oral SP, the pharmacokinetic properties of α/ß-AE were not significantly affected, and α/ß-AE had no significant effect on the pharmacokinetic properties of SP in these selected groups of healthy volunteers. However, more investigations are needed to explore this further. (This study has been registered in the clinical trial registry of India under approval no. CTRI/2011/11/002155.).

A British Society of Paediatric Gastroenterology, Hepatology and Nutrition survey of the effectiveness and safety of adalimumab in children with inflammatory bowel disease.

BACKGROUND: Adalimumab is efficacious therapy for adults with Crohn's disease (CD). AIM: To summarise the United Kingdom and Republic of Ireland paediatric adalimumab experience. METHODS: British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) members with Inflammatory Bowel Disease (IBD) patients <18 years old commencing adalimumab with at least 4 weeks follow-up. Patient demographics and details of treatment were then collected. Response and remission was assessed using the Paediatric Crohn's Disease Activity Index (PCDAI)/Physicians Global Assessment (PGA). RESULTS: Seventy-two patients [70 CD, 1 ulcerative colitis (UC), 1 IBD unclassified (IBDU)] from 19 paediatric-centres received adalimumab at a median age of 14.8 (IQR 3.1, range 6.1-17.8) years; 66/70 CD (94%) had previously received infliximab. A dose of 80 mg then 40 mg was used for induction in 41(59%) and 40 mg fortnightly for maintenance in 61 (90%). Remission rates were 24%, 58% and 41% at 1, 6 and 12 months, respectively. Overall 43 (61%) went into remission at some point, with 24 (35%) requiring escalation of therapy. Remission rates were higher in those on concomitant immunosuppression cf. those not on immunosuppression [34/46 (74%) vs. 9/24 (37%), respectively, (χ(2) 8.8, P=0.003)]. There were 15 adverse events (21%) including four (6%) serious adverse events with two sepsis related deaths in patients who were also on immunosuppression and home parenteral nutrition (3% mortality rate). CONCLUSIONS: Adalimumab is useful in treatment of refractory paediatric patients with a remission rate of 61%. This treatment benefit should be balanced against side effects, including in this study a 3% mortality rate.

Malignant rhabdoid tumour of the third ventricle.

A 16-year-old boy presented to the All India Institute of Medical Sciences hospital with signs and symptoms of raised intracranial pressure. A CT scan showed obstructive hydrocephalus from a large posterior third ventricle mass lesion. The patient underwent a subtotal resection of the tumour, followed by radiotherapy. Histological, ultrastructural and immunohistochemical features of the tumour were consistent with primary malignant rhabdoid tumour. The age of presentation and location of the lesion were unusual.

Composite pituitary adenoma and intrasellar tuberculoma: report of a rare case.

Tuberculous involvement of the pituitary gland is rare. We report a unique case of a composite lesion consisting of pituitary adenoma and intrasellar tuberculoma. A 24-year-old lady presented with features of acromegaly and amenorrhea. Serum growth hormone levels were found to be raised. Radiological investigations were consistent with a pituitary adenoma. Decompression of the lesion was done through trans-sphenoidal approach. Histological examination revealed a growth hormone secreting pituitary adenoma in association with a granulomatous lesion suggesting of pituitary tuberculoma. No other evidence of tuberculosis was found in the brain or spinal cord. This type of dual pathology has been reported only once in the earlier literature.

Role of yoga in management of essential hypertension.

Twenty five patients of essential hypertension were studied. Of these, 20 patients were not given any antihypertensive drug treatment (Group A); other 5 had to be put on antihypertensive drugs before including them in the study (Group B). These patients were demonstrated "Shavasana" and trained to perform it correctly. Shavasana therapy was continued for six months. There was a statistically significant fall in both mean systolic and diastolic pressure of both groups. Further, there was a significant reduction in doses of antihypertensive drugs, being given to patients of group B. In 65% patients of group A, blood pressure could be controlled with Shavasana only and no drug was needed in them at all. Blood pressure rose significantly to pre-Shavasana levels in patients who left practising yoga. Thus, with use of yoga (Shavasana) in therapy of hypertension, requirement of antihypertensive drugs may be significantly decreased and in some cases may be totally dispensed with and it may be an useful adjunct in treatment of hypertension.

Digoxin toxicity and electrolytes: a correlative study.

Serum levels of sodium, potassium, calcium, magnesium and digoxin were studied in 67 patients on maintenance dose of digoxin, 42 with digitoxicity and 25 without. The mean serum digoxin level of toxic group was significantly higher (p less than 0.001) than non-toxic group. The mean serum potassium was significantly lower in toxic group (p less than 0.05) as compared to the non-toxic group. Of the toxic patients, 23.8% had hypokalemia. Hypokalemia resulted by significantly higher (p less than 0.005) dose of diuretic used in toxic group. The mean serum digoxin level of hypokalemic toxic group was significantly lower as compared to the normokalemic toxic group (p less than 0.001) and it was interesting to note that all hypokalemic toxic patients had their serum digoxin levels below 3 ng/ml (3.84 n mol/ml) and well within therapeutic range. There was a positive correlation between serum digoxin and potassium level amongst toxic patients (p less than 0.001). Thus, in patients on maintenance dose of digoxin therapy, use of large dosage of diuretics may result in hypokalemia, causing digitalis toxicity even at low serum digoxin levels. Serum digoxin level alone may fail as an independent guide in diagnosis of digoxin toxicity in presence of hypokalemia.

Scleredema-some Unusual Features.

Two cases of adult scletedema have been reported. The unusual electrocardiographic features and association with pulmonary tuberculosis in these cases of scleredema are described. The salient features have been highlighted and relevant literature has been reviewed.

Ratio of LDH isozymes H4 and H3M as diagnostic index in suspected cases of myocardial infarction.

The isozyme profile of lactic dehydrogenase (LDH) is being studied in this laboratory, mainly for the diagnosis in the suspected cases of myocardial infarction (MI). The isozymes are separated by polyacrylamide gel electrophoresis and the quantitative assay of the isoenzymes is done by enzyme staining followed by scanning with the help of an automatic scanner. In normal cases, the ratio of the two isozymes H4 and H3M is approximately 0.5. In almost all cases of myocardial infarction the ratio becomes 1 or more and sometimes increases up to 2. In the suspected and potential cases of infarction the ratio tends to become more than 0.5 (usually 0.7) but remains lower than 1. Thus, the measurement of the ratio may be a very helpful diagnostic index in the suspected and potential cases and may also be used for prognostic purposes as well.