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.

Drug-herb interaction: database of medicinal plants of the Caribbean, their indications, toxicities and possible interactions with conventional medication.

OBJECTIVE: Healthcare professionals in the Caribbean today know very little about these drug-herb interactions of the popular West Indian medicinal herb practices linked to the immigrants from West Africa and India, and to the indigenous Amerindians. It is the intent of this project to produce a database which comprehensively summarizes indications and possible drug-herb interactions of these plants. METHOD: Using the database programme Epi Info 3.5.1, one hundred and eighty-three herbs used in the Caribbean as medicine by locals have been entered into the West Indian Drug Herb Interaction Database version 0.06 (WIDHID 0.06). RESULTS: A range of one to three common names have been entered with the family and scientific name of each herb, in addition to a range of one to six conditions/illnesses for which a particular plant was to be used as a medicinal herb. One to four bioactive compounds have been made to correlate with the typical herbal preparation methods and toxicity. Thirty of the most common and popular herbs have been researched for their drug herb interactions. CONCLUSION: West Indian Drug Herb Interaction Database version 0.06 for the first time allows easy access to Caribbean ethno-medicinal plant cures with their possible drug-herb interactions reference sources, a feature often absent although so important. In addition, WIDHID 0.06 will support pharmaco-epidemiological studies in the field. It will also ensure future public access to ethno-medicinal information through developed web pages or programmes.

Health human resource planning in Barbados and the eastern Caribbean states: a matter of sustainability.

Health and Human Resources (HHR) are very important issues to be considered in healthcare services. While various factors may be of greater significance in one area depending on resources, priorities and stage of economic development, a robust HHR plan is important in all cases. There are many factors such as demographic shifts, changing delivery models, consumer expectations, global shortages and financial restraints that must be considered in proper HHR planning. This manuscript summarizes some of the factors that should be considered and some of the short comings of current HHR planning approaches. Based on our review and experience, we developed a framework for HHR planning and apply the framework to Barbados to try to identify the existing challenges and issues and potential areas for staff and training investments.

Speaking the same language: treatment outcome definitions for multidrug-resistant tuberculosis.

SETTING: Globally it is estimated that 273000 new cases of multidrug-resistant tuberculosis (MDR-TB, resistance to isoniazid and rifampicin) occurred in 2000. To address MDR-TB management in the context of the DOTS strategy, the World Health Organization and partners have been promoting an expanded treatment strategy called DOTS-Plus. However, standard definitions for MDR-TB patient registration and treatment outcomes do not exist. OBJECTIVE: To propose a standardized set of case registration groups and treatment outcome definitions for MDR-TB and procedures for conducting cohort analyses under the DOTS-Plus strategy. DESIGN: Using published definitions for drug-susceptible TB as a guide, a 2-year-long series of meetings, conferences, and correspondence was undertaken to review published literature and country-specific program experience, and to develop international agreement. RESULTS: Definitions were designed for MDR-TB patient categorization, smear and culture conversion, and treatment outcomes (cure, treatment completion, death, default, failure, transfer out). Standards for conducting outcome analyses were developed to ensure comparability between programs. CONCLUSION: Optimal management strategies for MDR-TB have not been evaluated in controlled clinical trials. Standardized definitions and cohort analyses will facilitate assessment and comparison of program performance. These data will contribute to the evidence base to inform decision makers on approaches to MDR-TB control.

Incidence of type I diabetes in people under 30 years of age in Barbados, West Indies, 1982-1991.

OBJECTIVE: To determine the incidence of type I diabetes among individuals < 30 years of age on the island of Barbados in the Caribbean. The population is predominantly African in origin but exhibits a relatively westernized lifestyle. RESEARCH DESIGN AND METHODS: Cases occurring during the years 1982-1991 were drawn from records at Queen Elizabeth Hospital and from physicians treating insulin-dependent diabetes mellitus (IDDM) patients. Patients using insulin and < 30 years of age at onset were included. Ascertainment was estimated at 94%. RESULTS: The average annual incidence of type I diabetes among Barbadians was 4.1/100,000 when age-adjusted to the world's population. There were 59 incident cases during this 10-year interval. The risk for males was 4.4 and for females 4.0/100,000. Among those 0-14 years of age, the risk was 5.0/100,000. Mean age at onset (+/- SD) was 14.7 +/- 6.9 for males and 12.5 +/- 5.7 for females. Males showed marked seasonal variation in risk and a more than threefold increase in annual incidence during 1984-1985. In contrast, females exhibited a stable pattern of IDDM risk during the 10-year interval. CONCLUSIONS: The incidence rate in Barbados falls near the lower limits of rates reported for Caribbean populations. There was a marked seasonal effect among males, even though the climate varies little throughout the year. This observation, and the incidence peak during 1984-1985, provide support for the role of environmental factors in the etiology of IDDM.

Blood pressure in blacks. Twin studies in Barbados.

We have recently reported that there are significant genetic influences on the population variation in blood pressure in black twins in Los Angeles. The present cross-sectional study was undertaken to replicate these findings in a black twin population that lives in a different biosocial environment. We chose the Caribbean island nation of Barbados, where 96% of the population is black, the literacy rate is 99%, and the access to health care is guaranteed. The goals were 1) to test the feasibility of twin studies in blood pressure research in a developing country and 2) to estimate the relative contribution of genes and environment to blood pressure variability in blacks in the Caribbean. The names of 200 twin sets were obtained with the assistance of community resources including a twin club, by media advertisement, and by asking people at public blood pressure screenings if they knew any twins. By using these methods, we identified 200 sets of twins. Of these, 37.5% (75/200) met our criteria for study. Although 97% of the sets of twins (73/75) said they were willing to participate, only 69% (52/75) were able to be scheduled during the 1 week of the study when the full team of investigators was in Barbados. Of those scheduled, 83% (43/52) were examined. Examination included medical history, physical examination, recumbent blood pressure measurements by two observers, anthropometric measurements, 24-hour urine collections for sodium and potassium tests, and blood tests for zygosity.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting antipyrine metabolism in West African villagers.

Saliva half-life of antipyrine was studied in 49 healthy Gambians between 20 and 60 yr of age of whom 27 were male (mean age, 44.5) and 22 female (mean age, 39.1). Body wieght, height, ponderal index, albumin, and hemoglobin were moderately reduced compared to accepted normal values. Antipyrine half-life was 13.6 +/- 0.58 (SEM) hr. Multiple regression analysis showed that sex, cola nut consumption, hemoglobin in women, and height in men were statiscally significant independent predictors of antipyrine half-life. Half-life was shorter in women, decreased with an increase in height in men, and was prolonged by cola nut consumption. Half-life in women increased with hemoglobin. These factors explained 36% of the variation and suggest that geographic differences in the environment could be important in drug metabolism in man.

Human T-lymphotropic virus type I DNA in spinal cord of tropical spastic paraparesis with concomitant human T-lymphotropic virus type I-negative Hodgkin's disease.

We studied a 58-year-old black woman from Barbados who simultaneously developed myelopathy and lymphoma with human T-lymphotropic virus type I (HTLV-I) antibodies in serum and cerebrospinal fluid and died 3 years after onset. Neuropathological examination showed typical tropical spastic paraparesis (TSP). The polymerase chain reaction (PCR) demonstrated defective proviral genome retaining the HTLV-I pX and env regions in thoracic spinal cord, the level most severely affected. Defective HTLV-I in the nervous system retaining the pX region may be relevant to pathogenesis because circulating CD8+ cytotoxic lymphocytes specific for HTLV-I pX occur in HTLV-I myelopathy. This patient's lymph node biopsy specimen was consistent with Hodgkin's disease (HD), nodular sclerosis subtype, of B-cell origin. The PCR in the paraffin-embedded lymph node involved by HD failed to amplify HTLV-I proviral sequences. Complete HTLV-I proviral amplification was obtained in paraffin-embedded lymph nodes form positive controls (adult T-cell leukemia). To our knowledge the association of TSP and HD has not been reported previously. Despite claims that HD may be associated with HTLV-I, we demonstrated absence of HTLV-I-infected T cells in the lymphoid infiltrate of HD in this case, positive HTLV-I serology notwithstanding.

Elevated systemic concentrations of soluble ICAM-1 (sICAM) are not reflected in the gingival crevicular fluid of smokers with periodontitis.

Raised serum levels of soluble intercellular adhesion molecule-1 (sICAM-1) in smokers could have immunomodulatory effects in periodontitis. The aim of this study was to compare serum and gingival crevicular fluid (GCF) concentrations of sICAM-1 in smokers and non-smokers with periodontal disease. sICAM-1 in serum and GCF collected from age- and gender-matched smokers (n = 14) and non-smokers (n = 14) with periodontitis were measured by ELISA. Mean serum sICAM-1 concentrations were significantly elevated in smokers (331 ng mL(-1)), compared with non-smokers (238 ng mL(-1), p = 0.008). However, the concentration of sICAM-1 in the GCF was significantly lower in the smokers (83 ng mL(-1)), compared with non-smokers (212 ng mL(-1), p = 0.013). The difference between concentrations of sICAM-1 in GCF and serum was significant only in smokers (p < 0.001). Since GCF is a serum-derived tissue exudate, these results suggest that, in smokers, circulating sICAM-1 molecules are affected either in their passage from the periodontal microvasculature or within the periodontal tissues.

An artificial neural network system for diagnosis of acute myocardial infarction (AMI) in the accident and emergency department: evaluation and comparison with serum myoglobin measurements.

Recent studies have confirmed that artificial neural networks (ANNs) are adept at recognising patterns in sets of clinical data. The diagnosis of acute myocardial infarction (AMI) in patients presenting with chest pain remains one of the greatest challenges in emergency medicine. The aim of this study was to evaluate the performance of an ANN trained to analyse clinical data from chest pain patients. The ANN was compared with serum myoglobin measurements--cardiac damage is associated with increased circulating myoglobin levels, and this is widely used as an early marker for evolving AMI. We used 39 items of clinical and ECG data from the time of presentation to derive 53 binary inputs to a back propagation network. On test data (200 cases), overall accuracy, sensitivity, specificity and positive predictive value (PPV) of the ANN were 91.8, 91.2, 90.2 and 84.9% respectively. Corresponding figures using linear discriminant analysis were 81.0, 77.9, 82.6 and 69.7% (P < 0.01). Using a further test set from a different centre (91 cases), the accuracy, sensitivity, specificity and PPV for the admitting physicians were 65.1, 28.5, 76.9 and 28.6% respectively compared with 73.6, 52.4, 80.0 and 44.0% for the ANN. Although myoglobin at presentation was highly specific, it was only 38.0% sensitive, compared with 85.7% at 3 h. Simple strategies to combine clinical opinion, ANN output and myoglobin at presentation could greatly improve sensitivity and specificity of AMI diagnosis. The ideal support for emergency room physicians may come from a combination of computer-aided analysis of clinical factors and biochemical markers such as myoglobin. This study demonstrates that the two approaches could be usefully combined, the major benefit of the decision support system being in the first 3 h before biochemical markers have become abnormal.

Using patient-reportable clinical history factors to predict myocardial infarction.

Using a derivation data set of 1253 patients, we built several logistic regression and neural network models to estimate the likelihood of myocardial infarction based upon patient-reportable clinical history factors only. The best performing logistic regression model and neural network model had C-indices of 0.8444 and 0.8503, respectively, when validated on an independent data set of 500 patients. We conclude that both logistic regression and neural network models can be built that successfully predict the probability of myocardial infarction based on patient-reportable history factors alone. These models could have important utility in applications outside of a hospital setting when objective diagnostic test information is not yet be available.

Writing a scientific paper.

There are many varieties of medical writing. This paper suggests a sound, practical approach for writing up a research project in the conventional format for a medical or scientific journal. The structure of a scientific paper is well established, to accommodate the "Why" of the project (the Introduction), the "Who, when, where and how" (the Methods) and the "What" (the Results). The Discussion (the "So what") should be in three parts--discussion and explanation of results, disputation, and disquisition (implications for practice and for future work). Guidelines are given for getting started and for producing a paper that will, hopefully, be published and read.

Research, health policies and health care in the Caribbean. The role of the University of the West Indies.

The University of the West Indies has had a major impact on the provision of health care and the health of Caribbean nations over the last 50 years, through undergraduate, postgraduate and continuing medical education, research, outreach and public service. These roles are fully accepted, and the Faculties of Medical Sciences and School of Clinical Medicine and Research have provided most of the doctors now serving the English-speaking Caribbean, including academic leaders and chief medical officers. The design of a curriculum to produce doctors "designed" for the region has been a well-articulated goal, and the need to carry out relevant and essential national health research is now accepted. But the broader roles of ensuring translation of research into policy and practice, and developing effective ways of promoting on-going continuing training and behaviour change are far from understood or seriously attempted. Communication of research findings and evidence-based practice is crucial. The West Indian Medical Journal clearly has a valuable role to play here and this requires expansion and support. But a multi-faceted approach to communicating research findings and translating evidence into policy, planning and care is necessary. One possible approach would be a University Unit of Health Policy Research and Development.

Variation in response to drugs: Part II. Environmental and nutritional variables.

PIP: The importance of environmental factors for drug metabolism has recently been established. This paper reviews the major environmental and nutritional sources of variation in drug response. Environmental variables examined include drug interactions, alcohol, cigarette smoking, marijuana, other socially used drugs, steroid oral contraceptives (OCs), and agricultural industrial contaminants. Drug-drug interactions act chiefly by induction or inhibition of the microsomal metabolizing enzyme system. The effect of alcohol on the metabolism of other drugs depends on the drug, the dose of alcohol, the duration of exposure, and possibly diet and the presence of disease. Cigarette smoke affects the biotransformation of several drugs, and smokers often require higher doses of oxidized drugs. An additive effect of cigarette smoke and marijuana has been observed, resulting in the halving of the half-life of some drugs. Caffeine may serve as a competitive inhibitor of microsomal enzymes. Chemical pollutants such as chlorinated and polycyclic hydrocarbons can alter the hepatic drug metabolizing enzyme activity. The nutritional variables examined include malnutrition, anemia, vegetarian diets, dietary contaminants, and specific microconstituents of diet. Total dietary protein has a more critical effect on drug metabolism than fat or carbohydrate. These findings indicate that many factors in each patient are capable of altering drug response. Assessment of these variables permits more rational prescribing practices. For example, most patients over age 70 or vegetarian OC users require half the usual dosage of most drugs, whereas smokers and industrial workers require higher than recommended doses. Plasma measurements are of value in such assessments. Developing countries are advised to encourage rational use of a restricted number of drugs through an understanding of the sources of variation in drug response. This requires communication between clinical pharmacologists, other clinicians, pharmacists, government agencies, and patients. A prescriber's formulary tailored to local needs is an essential component of any plan to improve drug therapy.^ieng

Use by visitors of the services of the Queen Elizabeth Hospital, Barbados, W.I.

This paper analyses data for 1990 culled from the medical records of the Queen Elizabeth Hospital, Barbados and examines the use of inpatient and emergency services by visitors to Barbados. The 473 visitors admitted represented 2.1% of all admissions. The records of 425 contained information on country of origin: 145 were from non-Caribbean and 280 from Caribbean countries. The distribution by country of non-Caribbean visitors was the same as that of regular tourist arrivals--the majority came from the USA. Canada and the UK. Caribbean visitors represented 14.4% of the tourists, but accounted for 65.9% of visitor admissions. Non-Caribbean visitors were 85.6% of tourists, but 34.1% of admissions. Young patients predominated among Caribbean, and older patients among non-Caribbean. Accidents, cardiovascular disease, alcohol-related illnesses and near drowning were commoner in the non-Caribbean visitors, while cancer and obstetrical/gynaecological problems were commoner in Caribbean visitors. Seven per cent of visitor admissions went to the Intensive Care Unit as against 0.15% of other patients. The average hospital stay of visitors was 11.7 days compared with 7.0 days for Barbadians. There were 898 visitors treated in the Accident and Emergency Department and the commonest problems were lacerations, abrasions and infections. The UK provided most of these patients. These data show that there is appreciable visitor use of the public health services. Non-Caribbean visitors use them because they fall ill on holiday, but many Caribbean visitors may come specifically for health care. The cost to the Barbadian health service is not insignificant: at the 1990 estimated bed-day cost of Bds$250, it represents a cost of Bds$1.1 million per annum to the Government for inpatient services alone, or 2% of total hospital costs.

Neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital, Barbados, 1987-1996.

This paper reports on neurological and neurosurgical referrals overseas from the Queen Elizabeth Hospital (QEH) for the period November 1987 to November 1996, and is a follow up to an earlier report for the period January 1984 to November 1987. It outlines the pattern of referral, diagnoses, referral centres and costs based on examination of the files of all QEH patients transferred overseas under a government aided scheme. There were 203 transfers of 191 patients (69 males, 122 females) including 10 patients who were transferred twice and one patient who was transferred three times. Patients' ages ranged from 1 to 80 years (mean 37 years). Twenty overseas centres were used during the period but most patients were transferred to Brooklyn Hospital, New York in 1988, Mount Sinai Medical Center, New York, between 1989 and 1994, and Hospital de Clinicas Caracas, Venezuela (1992 to 1996). 65% of the referrals were for neurosurgery and 25% were for magnetic resonance imaging scans for diagnosis. The largest diagnostic categories were central nervous system tumors (40%) and subarachnoid haemorrhage (25%). Estimated costs reached almost BDS$11 million, but the mean actual cost was BDS$63,916 based on information from 123 patient transfers. Thus, the actual total government expenditure was probably closer to BDS$13 million. This study demonstrates the urgent need to establish a neurosurgical service at the QEH and the cost effectiveness of doing so.

Using classification tree and logistic regression methods to diagnose myocardial infarction.

Early and accurate diagnosis of myocardial infarction (MI) in patients who present to the Emergency Room (ER) complaining of chest pain is an important problem in emergency medicine. A number of decision aids have been developed to assist with this problem but have not achieved general use. Machine learning techniques, including classification tree and logistic regression (LR) methods, have the potential to create simple but accurate decision aids. Both a classification tree (FT Tree) and an LR model (FT LR) have been developed to predict the probability that a patient with chest pain is having an MI based solely upon data available at time of presentation to the ER. Training data came from a data set collected in Edinburgh, Scotland. Each model was then tested on a separate Edinburgh data set, as well as on a data set from a different hospital in Sheffield, England. Previously published models, the Goldman classification tree[1] and Kennedy LR equation[2], were evaluated on the same test data sets. On the Edinburgh test set, results showed that the FT Tree, FT LR, and Kennedy LR performed equally well, with ROC curve areas of 94.04%, 94.28%, and 94.30%, respectively, while the Goldman Tree's performance was significantly poorer, with an area of 84.03%. The difference in ROC areas between the first three models and the Goldman model is significant beyond the 0.0001 level. On the Sheffield test set, results showed that the FT Tree, FT LR, and Kennedy LR ROC areas were not significantly different (p > = 0.17), while the FT Tree again outperformed the Goldman Tree (p = 0.006). Unlike previous work[3], this study indicates that classification trees, which have certain advantages over LR models, may perform as well as LR models in the diagnosis of patients with MI.

TeleMedMail: free software to facilitate telemedicine in developing countries.

Telemedicine offers the potential to alleviate the severe shortage of medical specialists in developing countries. However lack of equipment and poor network connections usually rule out video-conferencing systems. This paper describes a software application to facilitate store-and-forward telemedicine by email of images from digital cameras. TeleMedMail is written in Java and allows structured text entry, image processing, image and data compression, and data encryption. The design, implementation, and initial evaluation are described.

Fifty years of clinical examinations at the University of the West Indies.

The University of the West Indies was founded at Mona, Jamaica, in 1948. After fifty-two years, the format of the final Bachelor of Medicine clinical examination in Medicine and Therapeutics has been radically revised. The change from the traditional to an evidence-based, objective structured clinical examination (OSCE) was undertaken in November/December 2000. Assessment drives learning and both the methods chosen for assessment and the manner in which they are applied determine how students learn. The philosophical underpinnings of the change in format are discussed in this paper.