Physician Opinions about EHR Use by EHR Experience and by Whether the Practice had optimized its EHR Use.

Optimization and experience with using EHRs may improve physician experiences. Physician opinions about EHR-related impacts, and the extent to which these impacts differ by self-reported optimized EHR use and length of experience are examined through nationally representative physician data of EHR users from the National Electronic Health Records Survey extended survey (n=1,471). Logistic regression models first estimated how physicians' length of times using an EHR were associated with each EHR-related impact. Additionally, a similar set of models estimated the association of self-reported optimized EHR use with each EHR impact. At least 70% of physicians using EHRs continue to attribute their administrative burdens to their EHR use. Physicians with 4 or more years of EHR experience accounted for 58% of those using EHRs. About 71% of EHR users self-reported using an optimized EHR. Physicians with more EHR experience and those in practices that optimized EHR use had positive opinions about the impacts of using EHRs, compared to their counterparts. These findings suggest that longer experience with EHRs improves perceptions about EHR use; and that perceived EHR use optimization is crucial to identifying EHR-related benefits. Finding ways to reduce EHR-related administrative burden has yet to be addressed.

Breathprints of childhood obesity: changes in volatile organic compounds in obese children compared with lean controls.

OBJECTIVE: The objective of this study was to investigate changes in volatile organic compounds (VOCs) in exhaled breath in overweight/obese children compared with their lean counterparts. STUDY DESIGN: Single exhaled breath was collected and analyzed per protocol using selective ion flow tube mass spectrometry (SIFT-MS). RESULTS: Sixty overweight/obese children and 55 lean controls were included. Compared with the lean group, the obese group was significantly older (14.1 ± 2.8 vs. 12.1 ± 3.0 years), taller (164.8 ± 10.9 vs. 153.3 ± 17.1 cm) and more likely to be Caucasian (60% vs. 35.2%); P < 0.05 for all. A comparison of the SIFT-MS results of the obese group with the lean group revealed differences in concentration of more than 50 compounds. A panel of four VOCs can identify the presence of overweight/obesity with excellent accuracy. Further analysis revealed that breath isoprene, 1-decene, 1-octene, ammonia and hydrogen sulfide were significantly higher in the obese group compared with the lean group (P value < 0.01 for all). CONCLUSION: Obese children have a unique pattern of exhaled VOCs. Changes in VOCs observed in this study may help to gain insight into pathophysiological processes and pathways leading to the development of childhood obesity.

Metabolomic analysis of breath volatile organic compounds reveals unique breathprints in children with inflammatory bowel disease: a pilot study.

BACKGROUND: Breath testing is becoming an important diagnostic method to evaluate many disease states. In the light of rising healthcare costs, is important to develop a simple non-invasive tool to potentially identify paediatric patients who need endoscopy for suspected inflammatory bowel disease (IBD). AIM: To analyse exhaled volatile organic compounds (VOCs) and investigate the presence of a unique breath patterns to differentiate paediatric patients with (IBD) from healthy controls. METHODS: A cross-sectional, single-centre study included paediatric IBD patients and healthy controls (age range, 5-21 years). The diagnosis of IBD was confirmed by endoscopic, histological and radiographic data. Exhaled breath was collected and analysed using a selective ion flow tube mass spectroscopy (SIFT-MS) to identify new markers or patterns of IBD. RESULTS: One hundred and seventeen patients (62 with IBD and 55 healthy controls) were included in the study. Linear discriminant analysis and principle component analysis of mass scanning ion peak data demonstrated 21 pre-selected VOCs correctly classify patients with IBD or as healthy controls; P < 0.0001. Multivariable logistic regression analysis further showed three specific VOCs (1-octene, 1-decene, (E)-2-nonene) had excellent accuracy for predicting the presence of IBD with an area under the curve (AUC) of 0.96 (95% CI: 0.93-0.99). No significant difference in VOCs was found between patients with Crohn's disease or ulcerative colitis, and no significant correlation was seen with disease activity. CONCLUSION: These pilot data support the hypothesis that a unique breathprint potentially exists for paediatric IBD in the exhaled metabolome.

Comparison of commercially available target enrichment methods for next-generation sequencing.

Isolating high-priority segments of genomes greatly enhances the efficiency of next-generation sequencing (NGS) by allowing researchers to focus on their regions of interest. For the 2010-11 DNA Sequencing Research Group (DSRG) study, we compared outcomes from two leading companies, Agilent Technologies (Santa Clara, CA, USA) and Roche NimbleGen (Madison, WI, USA), which offer custom-targeted genomic enrichment methods. Both companies were provided with the same genomic sample and challenged to capture identical genomic locations for DNA NGS. The target region totaled 3.5 Mb and included 31 individual genes and a 2-Mb contiguous interval. Each company was asked to design its best assay, perform the capture in replicates, and return the captured material to the DSRG-participating laboratories. Sequencing was performed in two different laboratories on Genome Analyzer IIx systems (Illumina, San Diego, CA, USA). Sequencing data were analyzed for sensitivity, specificity, and coverage of the desired regions. The success of the enrichment was highly dependent on the design of the capture probes. Overall, coverage variability was higher for the Agilent samples. As variant discovery is the ultimate goal for a typical targeted sequencing project, we compared samples for their ability to sequence single-nucleotide polymorphisms (SNPs) as a test of the ability to capture both chromosomes from the sample. In the targeted regions, we detected 2546 SNPs with the NimbleGen samples and 2071 with Agilent's. When limited to the regions that both companies included as baits, the number of SNPs was ∼1000 for each, with Agilent and NimbleGen finding a small number of unique SNPs not found by the other.

Are early and late preeclampsia distinct subclasses of the disease--what does the placenta reveal?

OBJECTIVE: To compare histopathological differences in placentas from early- and late-onset preeclampsia, as well as late-onset preeclampsia and normal term deliveries. METHODS: This prospective study was performed at Tygerberg Hospital, a secondary and tertiary referral center in South Africa. Placentas from 100 women, 25 each with early and late-onset preeclampsia, and an equal number of controls matched for gestational age, underwent routine preparation and were evaluated independently by two pathologists in a strictly predetermined, standardized manner. RESULTS: Compared to late preeclampsia, placentas in the early preeclampsia group were smaller (p < 0.01), had more infarction (odds ratio [OR] = 4.03, 95% confidence interval [CI] = 1.2-13.5) and inappropriate maturation (OR = 16.62, 95% CI = 4.1-68.0). Placentas from the late-onset preeclampsia group showed increased decidual arteriopathy (OR = 5.09, 95% CI = 1.45-17.92) and abruptio placentae (OR = 5.41, 95% CI = 1.01-28.79) compared to controls. CONCLUSIONS: The early- and late-onset preeclampsia placentas showed clear histopathological differences, whereas late-onset preeclampsia and normal term placentas differed less. These findings support the contention that early- and late-onset preeclampsia are different subclasses of disease.

Late onset preeclampsia is not an innocuous condition.

OBJECTIVE: To describe the profile and outcome of late-onset preeclampsia (LOPE). METHODS: Retrospective study of 264 singleton pregnancies presenting before delivery at two referral centres in South Africa. RESULTS: Primigravid patients constituted 56.8% of the group, while 57.6% were graded as severe. Median gestational age at diagnosis was 37 (34-43) weeks. 30.7% of patients experienced >or=1 major maternal complication including 34 (12.9%) cases of eclampsia. There were no maternal or early neonatal deaths. Five intrauterine deaths occurred, all due to placental abruption. The perinatal mortality rate was 18.9 per thousand births. CONCLUSIONS: Late-onset preeclampsia often presents as severe disease.

Longitudinal developmental profile of children from low socio-economic circumstances in Cape Town, using the 1996 Griffiths Mental Development Scales.

BACKGROUND: The Griffiths Mental Development Scales (GMDS) have not been standardised in South African children Neurodevelopmental scores of infants from deprived environments decline with age, but there is no evidence on how young South African children from such backgrounds perform on serial assessments. AIM: To describe the longitudinal developmental profile of infants from low socio-economic backgrounds at Tygerberg Children's Hospital by comparing the GMDS scores performed at 10 - 12 months and 20 - 22 months. METHODS: Infants born to HIV-uninfected women attending the public service programme were recruited from a vaccine study in Cape Town, South Africa. The GMDS 0 - 2 years and a neurological examination were performed between 10 and 12 months and between 20 and 22 months. RESULTS: Thirty-one infants (14 girls, 17 boys) were assessed. Their mean (standard deviation (SD)) age was 11.6 (0.8) months and 21.0 (0.5) months at the first and second assessments, respectively. The mean (SD) general quotient decreased significantly from 107.3 (11.7) to 95.0 (11.0) (p<0.001). All sub-quotients decreased significantly except for locomotor. The hearing and language sub-quotient was most affected, with a decrease in mean quotients from 113.0 to 93.2 (p<0.001). There was no evidence of intercurrent events to explain the decline. INTERPRETATION: Scores on the GMDS of this group of children from low socio-economic backgrounds were normal at 11 months and, other than locomotor, decreased significantly at 21 months, with language the most affected. Further research is needed to determine the specific reasons for the decline.

Outcome of Pregnancy in the Morbidly Obese Woman

Background: Obesity is a growing global health problem. In South Africa; more than half of the adult women are overweight and almost 30are obese. The problems associated with obesity; such as diabetes; hypertension; thrombo-embolism and coronary heart disease; are well described in the non-pregnant population; but the condition itself holds specific risks during the ante-; intra- and postpartum periods of the pregnant woman. Of particular concern is the intrapartum period. Complications such as slow progress during labour and increased rates of caesarean section are best addressed proactively. For this reason certain sources advocate that all morbidly obese women be referred for evaluation of the pregnancy and planning of labour and delivery by an anaesthetist and a specialist obstetrician. The aim of this study was to determine whether morbidly obese women are at increased risk of adverse outcomes; compared to women with a normal body mass index (BMI). Methods: A case control study design was used. In this study a normal BMI was defined as 20-25 kg/m2 and morbid obesity as a BMI of = 40 kg/m2. The BMI was calculated from the weight and height measured at the booking visit. The cases in this study comprised the first hundred morbidly obese women seen at the Obstetric Special Care Clinic in Tygerberg Hospital (TBH); a secondary and tertiary referral centre. The controls (n = 209) were women with normal BMIs and singleton pregnancies who booked as low-risk patients at the Bishop Lavis Midwife Obstetric Unit (MOU) during the same calendar period. A minimum ratio of 2:1 controls-to-case was used; with controls also matched for primi- or multiparity. Patients booking at the MOU with significant obstetric risk factors are referred to TBH for antenatal care. These women were not considered as controls. However; low-risk women who met the inclusion criteria at booking and who subsequently developed risks or complications were included; as the selection was done according to findings at the booking visit. The main outcomes to be determined were: ante-; intra- and postpartum maternal complications; rate of epidurals; and perinatal outcomes. Results: Women in the morbidly obese group were significantly older (p 0.001) and of higher parity (p 0.001) than those with normal BMIs. There was no difference in the numbers of primigravidae. Significantly more women in the morbidly obese group had experienced at least one miscarriage (p received it. During delivery; perineal damage was more common in morbidly obese women (p 0.001) and their babies were significantly larger (p 0.001). There was one perinatal death. Conclusions: Morbidly obese women experienced increased complications during pregnancy and childbirth. Due to the high rate of caesarean sections and the potential difficulties of emergency anaesthesia among these women; epidural anaesthesia during labour should be planned and administered as often as possible

Differential patterns of allelic loss in estrogen receptor-positive infiltrating lobular and ductal breast cancer.

The two main histological types of infiltrating breast cancer, lobular (ILC) and the more common ductal (IDC) carcinoma are morphologically and clinically distinct. To assess the molecular alterations associated with these breast cancer subtypes, we conducted a whole-genome study of 166 archival estrogen receptor (ER)-positive tumors (89 IDC and 77 ILC) using the Affymetrix GeneChip(R) Mapping 10K Array to identify sites of loss of heterozygosity (LOH) that either distinguished, or were shared by, the two phenotypes. We found single nucleotide polymorphisms (SNPs) of high-frequency LOH (>50%) common to both ILC and IDC tumors predominately in 11q, 16q, and 17p. Overall, IDC had a slightly higher frequency of LOH events across the genome than ILC (fractional allelic loss = 0.186 and 0.156). By comparing the average frequency of LOH by chromosomal arm, we found IDC tumors with significantly (P < 0.05) higher frequency of LOH on 3p, 5q, 8p, 9p, 20p, and 20q than ILC tumors. We identified additional chromosomal arms differentiating the subtypes when tumors were stratified by tumor size, mitotic rate, or DNA content. Of 5,754 informative SNPs (>25% informativity), we identified 78 and 466 individual SNPs with a higher frequency of LOH (P < 0.05) in ILC and IDC tumors, respectively. Hierarchical clustering of these 544 SNPs grouped tumors into four major groups based on their patterns of LOH and retention of heterozygosity. LOH in chromosomal arms 8p and 5q was common in higher grade IDC tumors, whereas ILC and low-grade IDC grouped together by virtue of LOH in 16q.

Successful control of Scedosporium prolificans septic arthritis and probable osteomyelitis without radical surgery in a long-term renal transplant recipient.

Scedosporium species are increasingly isolated from immunocompromised and immunocompetent patients. Scedosporium infections are generally resistant to multiple antifungals, and Scedosporium prolificans is particularly resistant to all single antifungal agents currently in use with in vitro testing. We report here a long-term renal transplant recipient who developed isolated S. prolificans septic monoarthritis and probable osteomyelitis. The infection was successfully treated with a combination of voriconazole and terbinafine in addition to joint washout but did not require radical surgery. This combination has been shown to have synergistic in vitro effect, and anecdotal in vivo success has also been reported recently. We also review the clinical presentation, treatment, and outcome of S. prolificans infection in patients with solid organ transplantation.

Intrauterine Deaths in High-Risk Pregnancies with Normal and Borderline Umbilical Artery Doppler Flow Velocity Waveforms

Objective. To investigate the use of a personal computer (PC)-based; continuous-wave Doppler device by a trained midwife at the fetal evaluation clinic at a tertiary hospital to assess flow velocity waveforms (FVWs) of the umbilical artery flow in referred women. Methods. Pregnant women referred for suspected poor fetal growth were evaluated from June 2002 through December 2004. The Umbiflow device (still prototype; developed by CSIR/MRC/Stellenbosch University); consisting of a Pentium 3 PC with an ultrasound transducer plugged into the USB port; was used to analyse the FVW of the umbilical artery. Pregnancies in which the resistance index (RI) was 75th percentile (P75) were not further evaluated for fetal well-being unless the clinical condition of the mother had changed. Pregnancies with an RI P75 were followed up according to a specific protocol. Primary endpoints were intrauterine death and intrauterine growth restriction. Results. Doppler FVWs were assessed in 955 pregnancies. The RI was P75 in 529 participants (55.4); between the P75 and P95 percentile in 350 (36.6) and P95 in 53 (5.5). In 23 cases (2.4) end-diastolic flow was absent or reversed (AREDF). Intrauterine death within 1 week of the test occurred in 1; 4; 0 and 2 women respectively in these four groups; and 16.7; 34.5; 54.9and 65.5respectively gave birth to infants that were small for gestational age. Conclusions. Intrauterine death; within 1 week of the test; was extremely rare when the RI was P75 (0.2). Relatively more deaths within a week of the Doppler examination occurred in the P75 - P95 group. This group should be regarded as being at high risk and needs careful antenatal surveillance

Nonlinear time series analysis of food intake in the dab and the rainbow trout.

Evidence suggests that dab and rainbow trout are able to quickly adjust their food intake to an appropriate level when offered novel diets. In addition day-to-day and meal-to-meal food intake varies greatly and meal timing is plastic. Why this is the case is not clear: Food intake in fish is influenced by many factors, however the hierarchy and mechanisms by which these interact is not yet fully understood. A model of food intake may be helpful to understand these phenomena; to determine model type it is necessary to understand the qualitative nature of food intake. Food intake can be regarded as an autoregressive (AR) time series, as the amount of food eaten at time t will be influenced by previous meals, and this allows food intake to be considered using time series analyses. Here, time series data were analysed using nonlinear techniques to obtain qualitative information from which evidence for the hierarchy of mechanisms controlling food intake may be drawn. Time series were obtained for a group of dab and individuals and a group of rainbow trout for analysis. Surrogate data sets were generated to test several null hypotheses describing linear processes and all proved significantly different to the real data, suggesting nonlinear dynamics. Examination of topography and recurrence diagrams suggested that all series were deterministic and non-stationary. The point correlation dimension (PD2i) suggested low-dimensional dynamics. Our findings suggest therefore that any model of appetite should create output that is deterministic, non-stationary, low-dimensional and having nonlinear dynamics.

The Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ) - Assessing Sexual Function of Urinary Incontinent Women in South Africa

Objective. To develop and psychometrically validate a questionnaire that assesses sexual function of urinary incontinent women in South Africa and the influence of inconti- nence on their sexual function. Design. A prospective descriptive study. Setting. Urogynaecology and gynaecology outpatient clinics at Tygerberg Hospital; Stellenbosch University; South Africa. Subjects. All patients attending the urogynaecology or gynaecology outpatient clinic at Tygerberg Hospital; who were older than 18 years; not pregnant and could communicate in either Afrikaans or eng. Outcome measures. The content validity; reliability (internal consistency) and construct validity (convergent and discrimi- nant validity) of the Sexual Function and Influence of Urinary Incontinence Questionnaire (SF-IUIQ). Results. Of the subjects 33were not sexually active. Sexual quality of life was significantly influenced by urinary incontinence in 37.7of individuals. Leakage during sexual activity occurred in 32.Conclusions. The SF-IUIQ is a reliable and valid measure of sexual function in urinary incontinent women; and ofthe influence of urinary incontinence on sexual function

Surface topography and vectors: a new measure for the three dimensional quantification of scoliotic deformity.

The monitoring of spinal deformity uses many techniques: clinical history and physical examination for patient status, radiography for precise spinal delineation and Cobb angle, topography to quantify cosmesis and to approximate the Cobb angle. Experience with a system based on Raster photography has shown that adequate correlation with the Cobb angle is achieved, but that the relationship between spinal curvature and cosmetic effect is not simple. A measure was developed to quantify the asymmetry of the back, making it available to statistical analysis, without expressing it in terms of the Cobb angle or referring to trunk balance or rotation. The calculation expresses symmetry about the median saggittal plane (first thoracic vertebra to natal cleft), reflecting the right half onto the left and measuring the three-dimensional displacement between corresponding fixed points on the trunk. Tolerance limits were calculated and correlation with Cobb angles using routine scans was analysed. There were statistically significant correlations between the Cobb angle and all vectors except the middle antero-posterior. All vectors correlated with each other, except again for the middle Z or anteroposterior which correlated only with the middle and lowermost sets. Applied to natural history and to surgical outcome, this new parameter provides a different quantification of back shape which can be used both for patient assessment and monitoring, for the evaluation of the cosmetic (as opposed to the radiological) effect of treatment, and for aetiology and natural history studies.

Postmenopausal hormone therapy and quality of life.

OBJECTIVE: To evaluate whether hormonal therapy (HT) had any significant effect on quality of life (QoL) in a selected group of postmenopausal women. METHODS: The study was conducted in a specialist private practice in Tygerberg, Cape Town, South Africa, over an 18-month period ending in July 2003. A questionnaire using the Utian Quality of Life (UQoL) scale was posted to all women with established postmenopausal status, seen over this period. 541 questionnaires were posted, 421 returned and 398 could be used. Women gave written informed consent. RESULTS: The average age of the women was 60 years. 313 women (78.6%) were using hormone therapy (HT) while 275 women (69.1%) reported concomitant medical problems. HT users had significantly higher scores in three of the four QoL domains, namely, occupational (p=0.046), emotional (p=0.03), and sexual (p=0.009). There was no significant difference in the health domain (p=0.2). CONCLUSION: This study found that post-menopausal South African women experienced that HT had a positive effect on global quality of life.

Prolonged outbreak of giardiasis with two modes of transmission.

Large outbreaks of giardiasis caused by person-to-person transmission, or a combination of transmission routes, have not previously been reported. A large, prolonged giardiasis outbreak affected families belonging to a country club in a suburb of Boston, Massachusetts, during June-December 2003. We conducted a retrospective cohort study to determine the source of this outbreak. Giardiasis-compatible illness was experienced by 149 (25%) respondents to a questionnaire, and was laboratory confirmed in 97 (65%) of these cases. Of the 30 primary cases, exposure to the children's pool at the country club was significantly associated with illness (risk ratio 3.3, 95% confidence interval 1.7-6.5). In addition, 105 secondary cases probably resulted from person-to-person spread; 14 cases did not report an onset date. This outbreak illustrates the potential for Giardia to spread through multiple modes of transmission, with a common-source outbreak caused by exposure to a contaminated water source resulting in subsequent prolonged propagation through person-to-person transmission in the community. This capacity for a common-source outbreak to continue propagation through secondary person-to-person spread has been reported with Shigella and Cryptosporidium and may also be a feature of other enteric pathogens having low infectious doses.

The attitudes of two groups of South African women towards mode of delivery.

OBJECTIVE: To determine whether 2 specific groups of women prefer vaginal or abdominal delivery. METHODS: Forty-six black and 54 colored (of mixed race, the predominant population group) primigravidas and 59 black and 62 colored multigravidas were interviewed between April 2003 and February 2004 at Tygerberg Hospital, Tygerberg, South Africa. RESULTS: Among primigravidas, 89% of black women and 83% of colored women preferred vaginal delivery. Among the multigravidas, 86% of black women and 79% of colored women preferred vaginal delivery. Most women believed that they would recover more quickly (65%) and with less pain (32%) after vaginal delivery. Forty-one percent of all women viewed episiotomy as the greatest disadvantage of vaginal delivery, while 43% were unaware of any advantage to cesarean delivery. CONCLUSION: Most colored and black women preferred vaginal over cesarean delivery. A challenge to healthcare personnel is to educate women about both routes.

Bacterial vaginosis diagnosed at the first antenatal visit better predicts preterm labour than diagnosis later in pregnancy.

This study was conducted as part of a double-blind randomised placebo-controlled trial, the aim of which was to determine whether vitamin C could reduce the recurrence risk of pre-term labour. In this study, women with a history of pre-term labour in a preceding pregnancy were randomised to receive either 250 mg vitamin C or a matching placebo twice daily until 34 weeks' gestation. They attended a dedicated pre-term labour clinic every 2 weeks. All women were screened for bacterial vaginosis (BV) at each visit. It was first determined that vitamin C did not have any effect on the presence of BV. Women who were diagnosed with BV before 20 weeks' gestation were at higher risk of delivering pre-term than those who developed BV after 20 weeks.

An outbreak of norovirus gastroenteritis associated with wedding cakes.

We sought to determine the source of a norovirus outbreak among attendees of 46 weddings taking place during a single weekend. Norovirus-compatible illness was experienced by 332 (39%) of wedding guests surveyed; the outbreak affected up to 2700 persons. Illness was associated with eating wedding cake provided by a bakery common to the weddings (adjusted RR 4.5, P<0.001). A cake requiring direct hand contact during its preparation accounted for the majority of illness. At least two bakery employees experienced norovirus-compatible illness during the week preceding the weddings. Identical sequence types of norovirus were detected in stool specimens submitted by two wedding guests, a wedding hall employee, and one of the ill bakery employees. It is likely that one or more food workers at the bakery contaminated the wedding cakes through direct and indirect contact. These findings reinforce the necessity of proper food-handling practices and of policies that discourage food handlers from working while ill.