Early Access to Electronic Health Records May Influence the Patient Experience.

In a recent Hot Topics column, Mehmet Sitki Copur, MD, FACP, et al discussed the pros and cons of patients receiving test results early through electronic medical records.

C-Sulfonylation of 4-Alkylpyridines: Formal Picolyl C-H Activation via Alkylidene Dihydropyridine Intermediates.

4-Picoline derivatives are converted to the corresponding aryl picolyl sulfones upon treatment with aryl sulfonyl chlorides and Et3N in the presence of catalytic DMAP. The reaction proceeds smoothly for a variety of alkyl and aryl picolines using a range of aryl sulfonyl chlorides. The reaction is believed to involve N-sulfonyl 4-alkylidene dihydropyridine intermediates and results in formal sulfonylation of unactivated picolyl C-H bonds.

Clinical information system (CIS) implementation in developing countries: requirements, success factors, and recommendations.

OBJECTIVE: Clinical Information System (CIS) usage can reduce healthcare costs over time, improve the quality of medical care and safety, and enhance clinical efficiency. However, CIS implementation in developing countries poses additional, different challenges from the developed countries. Therefore, this research aimed to systematically review the literature, gathering and integrating research findings on Success Factors (SFs) in CIS implementation for developing countries. This helps to integrate past knowledge and develop a set of recommendations, presented as a framework, for implementing CIS in developing countries. MATERIALS AND METHODS: A systematic literature review was conducted, followed by qualitative data analysis on the published articles related to requirements and SF for CIS implementation. Eighty-three articles met the inclusion criteria and were included in the data analysis. Thematic analysis and cross-case analysis were applied to identify and categorize the requirements and SF for CIS implementation in developing countries. RESULTS: Six major requirement categories were identified including project management, financial resources, government involvement and support, human resources, organizational, and technical requirements. Subcategories related to SF are classified under each major requirement. A set of recommendations is provided, presented in a framework, based on the project management lifecycle approach. CONCLUSION: The proposed framework could support CIS implementations in developing countries while enhancing their rate of success. Future studies should focus on identifying barriers to CIS implementation in developing countries. The country-specific empirical studies should also be conducted based on this research's findings to match the local context.

Mode of Detection of Second Events in Routine Surveillance of Early Stage Breast Cancer Patients.

INTRODUCTION: NCCN and ASCO guidelines recommend breast cancer (BC) follow-up to include clinical breast examination (CBE) every 6 months and annual mammography (AM) for 5 years. Given limited data to support CBE, we evaluated the modes of detection (MOD) of BC-events in a contemporary practice. METHODS: We conducted a retrospective review of registry patients with early stage BC (DCIS, Stage I or II) diagnosed between 2010 and 2015 with at least 5 years of follow-up. Second events were defined as malignant (contralateral primary, ipsilateral breast tumor recurrence (IBTR), chest wall recurrence, regional node recurrence or distant relapse) or benign. MOD was categorized as patient complaint, clinical examination or breast imaging. RESULTS: Sixty-three of 351 BC patients experienced second events. 15 had BC malignant events, including 4 distant disease, 5 contralateral primary, and 3 IBTR. 7/8 of IBTR and contralateral primary BC were AM detected. Patient complaints identified 4/4 distant relapses. Clinical exam identified 2/2 chest wall recurrences in post-mastectomy patients. CONCLUSIONS: Only 2.8% (10/351) of early stage BC patients experienced recurrence during 5 years of follow-up. AM was the predominate MOD of both IBTR and new contralateral primary following breast conserving therapy. Patient complaints prompted evaluation for distant disease. Provider CBE was MOD in only 2/351, 0.6% 95% CI (2.1%-0.1%) of patients as chest wall recurrences postmastectomy. Given modern enhancements to imaging and lower recurrence rates, this data encourages the reassessment of guidelines for every 6-month CBE and provides basis to study telehealth in survivorship care.

Imidazolidine Hydride Donors in Palladium-Catalyzed Alkyne Hydroarylation.

Aldehyde-derived imidazolidines participate as hydride donors in intramolecular reductive Heck-type reactions. N,N'-Diphenylimidazolidines prepared from ortho-alkynyl benzaldehydes underwent regio- and stereoselective palladium-catalyzed hydroarylation followed by formal 1,5-hydride transfer and reductive elimination to afford substituted alkenes and imidazolium moieties, the latter conveniently converted in situ to ring-opened benzanilides to simplify product isolation. Internal alkynes were converted to trisubstituted alkenes via a syn hydroarylation process, while a terminal alkyne was converted to a cis alkene via a formal trans hydroarylation reaction. Benzanilide products could be converted to carboxylic acid derivatives under basic conditions, resulting in the net conversion of alkynyl aldehydes to alkenyl carboxylic acids. A styrene derivative with an attached N,N'-dimethylbenzimidazoline hydride donor was also found to undergo an analogous hydroarylation/benzimidazoline oxidation to give a diarylethane product.

Complete Pathologic Response to Neoadjuvant Chemoimmunotherapy and Oxaliplatin-Induced Fever Associated With IL-6 Release in a Patient With Locally Advanced Colon Cancer

Neoadjuvant systemic therapy is a preferred treatment approach for a number of tumor types due to many potential advantages over upfront surgery, including tumor downstaging, early treatment of micrometastatic disease, and providing an in vivo test of tumor biology. For colon cancer, current standard of care is upfront surgery followed by adjuvant systemic therapy in high-risk patients. Concerns about inaccurate radiological staging and tumor progression during preoperative treatment, as well the lack of randomized data demonstrating benefit, are among the reasons for the limited use of neoadjuvant therapy in this disease. Locally advanced colon cancer, defined as primary colon cancer with direct invasion into the adjacent structures or extensive regional lymph node involvement, is not always amenable to pathological complete resection, and when attempted it comes with high incidence of postoperative morbidity and mortality because of the required multivisceral resection. Clinical trials of neoadjuvant chemotherapy for colon cancer to date have been promising with downstaging of disease and higher rates of R0 resection. Here, we report a case of a patient with locally advanced, unresectable, mismatch repair deficient sigmoid colon cancer who was treated with neoadjuvant chemoimmunotherapy followed by surgical resection leading to a complete pathologic response after preoperative systemic chemoimmunotherapy.

Internet of things (IoT) applications for elderly care: a reflective review.

Increasing in elderly population put extra pressure on healthcare systems globally in terms of operational costs and resources. To minimize this pressure and provide efficient healthcare services, the application of the Internet of Things (IoT) and wearable technology could be promising. These technologies have the potential to improve the quality of life of the elderly population while reducing strain on healthcare systems and minimizing their operational cost. Although IoT and wearable applications for elderly healthcare purposes were reviewed previously, there is a further need to summarize their current applications in this fast-developing area. This paper provides a comprehensive overview of IoT and wearable technologies' applications including the types of data collected and the types of devices for elderly healthcare. This paper provides insights into existing areas of IoT/wearable applications while presenting new research opportunities in emerging areas of applications, such as robotic technology and integrated applications. The analysis in this paper could be useful to healthcare solution designers and developers in defining technology supported futuristic healthcare strategies to serve elderly people and increasing their quality of life.

Extracellular RNA Profile in Mesenteric Lymph from Exemplar Rat Models of Acute and Critical Illness.

Background: Mesenteric lymph (ML) has been implicated in the development of multiple organ dysfunction syndrome in critical illness. Extracellular RNAs play a role in cell-to-cell communication during physiological and disease processes but they are rarely studied in ML. We aimed at examining the RNA profiles of peripheral plasma, ML, and ML's extracellular vesicle (ML-EV) and triglyceride-rich lipoprotein (ML-TRL) fractions, obtained from rodent models of critical illness. Methods and Results: We collected ML for 5 hours from rodent models of critical illness [Acute Pancreatitis, Cecal Ligation and Incision (CLI), Gut Ischemia-Reperfusion (IR)] and matching Sham control rats. ML-EV and ML-TRL fractions were also isolated. RNA sequencing was performed on the RNA extracted from ML, ML-EV, ML-TRL, and plasma by using the Ion Torrent Personal Genome Machine platform. RNA sequences were searched using the Basic Local Alignment Search Tool against rat genome and RefSeq, microRNA (miRNA), genomic tRNA, functional RNA, and Genbank nucleotide databases, and the read counts were analyzed. Each sample type had a distinct RNA profile. ML contained more RNA per volume and a larger proportion of tRNA fragments than plasma. ML-EVs were enriched with miRNA, whereas ML-TRLs contained low absolute amounts of RNA. The RNA size profiles for CLI and Gut IR were different from Sham. ML carried intestinal RNAs and in a CLI model it was significantly enriched with bacterial RNA sequences. Conclusions: We found the distinct but diverse RNA profiles of ML and its compartments, and their different profiles in critical illness. Intestinal-derived small RNAs in ML may have a direct role in critical illness and utility as potential biomarkers.

Altered Metabolic Profile of Triglyceride-Rich Lipoproteins in Gut-Lymph of Rodent Models of Sepsis and Gut Ischemia-Reperfusion Injury.

BACKGROUND: Triglyceride-rich lipoproteins are important in dietary lipid absorption and subsequent energy distribution in the body. Their importance in the gut-lymph may have been overlooked in sepsis, the most common cause of critical illness, and in gut ischemia-reperfusion injury, a common feature of many critical illnesses. AIMS: We aimed to undertake an exploratory study of triglyceride-rich lipoprotein fractions in gut-lymph using untargeted metabolic profiling to identify altered metabolites in sepsis or gut ischemia-reperfusion. METHODS: The gut-lymph was collected from rodent sham, sepsis, and gut ischemia-reperfusion models. The triglyceride-rich lipoprotein-enriched fractions isolated from the gut-lymph were subjected to a dual metabolomics analysis approach: non-polar metabolite analysis by ultra-high performance liquid chromatography-mass spectrometry and polar metabolite analysis by gas chromatography-mass spectrometry. RESULTS: The metabolite analysis of gut-lymph triglyceride-rich lipoprotein fractions revealed a significant increase (FDR-adjusted P value < 0.05) in myo-inositol in the sepsis group and monoacylglycerols [(18:1) and (18:2)] in gut ischemia-reperfusion. There were no significantly increased specific metabolites in the lipoprotein-enriched fractions of both sepsis and gut ischemia-reperfusion. In contrast, there was a widespread decrease in multiple lipid species in sepsis (35 out of 190; adjusted P < 0.05), but not in the gut ischemia-reperfusion. CONCLUSIONS: Increased levels of myo-inositol and monoacylglycerols, and decreased multiple lipid species in the gut-lymph triglyceride-rich lipoprotein fraction could be candidates for new biomarkers and/or involved in the progression of sepsis and gut ischemia-reperfusion pathobiology.

Lipid profiles and determinants of total cholesterol and hypercholesterolaemia among 25-74 year-old urban and rural citizens of the Yangon Region, Myanmar: a cross-sectional study.

OBJECTIVE: The first is to estimate the prevalence of dyslipidaemia (hypercholesterolaemia, hypertriglyceridaemia, high low-density lipoprotein (LDL) level and low high-density lipoprotein (HDL) level), as well as the mean levels of total cholesterol, triglyceride, LDL and HDL, in the urban and rural Yangon Region, Myanmar. The second is to investigate the association between urban-rural location and total cholesterol. DESIGN: Two cross-sectional studies using the WHO STEPS methodology. SETTING: Both the urban and rural areas of the Yangon Region, Myanmar. PARTICIPANTS: A total of 1370 men and women aged 25-74 years participated based on a multistage cluster sampling. Physically and mentally ill people, monks, nuns, soldiers and institutionalised people were excluded. RESULTS: Compared with rural counterparts, urban dwellers had a significantly higher age-standardised prevalence of hypercholesterolaemia (50.7% vs 41.6%; p=0.042) and a low HDL level (60.6% vs 44.4%; p=0.001). No urban-rural differences were found in the prevalence of hypertriglyceridaemia and high LDL. Men had a higher age-standardised prevalence of hypertriglyceridaemia than women (25.1% vs 14.8%; p<0.001), while the opposite pattern was found in the prevalence of a high LDL (11.3% vs 16.3%; p=0.018) and low HDL level (35.3% vs 70.1%; p<0.001).Compared with rural inhabitants, urban dwellers had higher age-standardised mean levels of total cholesterol (5.31 mmol/L, SE: 0.044 vs 5.05 mmol/L, 0.068; p=0.009), triglyceride (1.65 mmol/L, 0.049 vs 1.38 mmol/L, 0.078; p=0.017), LDL (3.44 mmol/L, 0.019 vs 3.16 mmol/L, 0.058; p=0.001) and lower age-standardised mean levels of HDL (1.11 mmol/L, 0.010 vs 1.25 mmol/L, 0.012; p<0.001). In linear regression, the total cholesterol was significantly associated with an urban location among men, but not among women. CONCLUSION: The mean level of total cholesterol and the prevalence of hypercholesterolaemia were alarmingly high in men and women in both the urban and rural areas of Yangon Region, Myanmar. Preventive measures to reduce cholesterol levels in the population are therefore needed.

Assessment of HIV testing among young methamphetamine users in Muse, Northern Shan State, Myanmar.

BACKGROUND: Methamphetamine (MA) use has a strong correlation with risky sexual behaviors, and thus may be triggering the growing HIV epidemic in Myanmar. Although methamphetamine use is a serious public health concern, only a few studies have examined HIV testing among young drug users. This study aimed to examine how predisposing, enabling and need factors affect HIV testing among young MA users. METHODS: A cross-sectional study was conducted from January to March 2013 in Muse city in the Northern Shan State of Myanmar. Using a respondent-driven sampling method, 776 MA users aged 18-24 years were recruited. The main outcome of interest was whether participants had ever been tested for HIV. Descriptive statistics and multivariate logistic regression were applied in this study. RESULTS: Approximately 14.7% of young MA users had ever been tested for HIV. Significant positive predictors of HIV testing included predisposing factors such as being a female MA user, having had higher education, and currently living with one's spouse/sexual partner. Significant enabling factors included being employed and having ever visited NGO clinics or met NGO workers. Significant need factors were having ever been diagnosed with an STI and having ever wanted to receive help to stop drug use. CONCLUSIONS: Predisposing, enabling and need factors were significant contributors affecting uptake of HIV testing among young MA users. Integrating HIV testing into STI treatment programs, alongside general expansion of HIV testing services may be effective in increasing HIV testing uptake among young MA users.

Taking stock of Myanmar's progress toward the health-related Millennium Development Goals: current roadblocks, paths ahead.

Myanmar is a developing country with considerable humanitarian needs, rendering its pursuit of the Millennium Development Goals (MDGs) an especially high priority. Yet progress to date remains under-examined on key fronts. Particularly within the three health-related MDGs (MDGs 4, 5, and 6), the limited data reported point to patchy levels of achievement. This study was undertaken to provide an overview and assessment of Myanmar's progress toward the health-related MDGs, along with possible solutions for accelerating health-related development into 2015 and beyond. The review highlights off-track progress in the spheres of maternal and child health (MDGs 4 and 5). It also shows Myanmar's achievements toward MDG 6 targets--in the areas of HIV/AIDS, malaria, and tuberculosis. Such achievements are especially notable in that Myanmar has been receiving the lowest level of official development assistance among all of the least developed countries in Asia. However, to make similar progress in MDGs 4 and 5, Myanmar needs increased investment and commitment in health. Toward moving forward with the post-2015 development agenda, Myanmar's government also needs to take the lead in calling for attention from the World Health Organization and its global development partners to address the stagnation in health-related development progress within the country. In particular, Myanmar's government should invest greater efforts into health system strengthening to pave the road to universal health coverage.

What are the factors associated with HIV testing among male injecting and non-injecting drug users in Lashio, Myanmar: a cross-sectional study.

OBJECTIVES: HIV testing is an effective intervention for reducing HIV risk and providing information on HIV status. However, uptake of HIV testing is a major challenge within the drug-using population due to the stigma and discrimination associated with their illegal drug use behaviours. This study thus aimed to identify factors associated with HIV testing among injecting drug users (IDUs) and non-injecting drug users (NIDUs) in Lashio, Myanmar. DESIGN: A cross-sectional study was conducted from January 2010 to February 2010. SETTING: This study was carried out in Lashio city, Northern Shan State, Myanmar. PARTICIPANTS: In total, 158 male IDUs and 210 male NIDUs were recruited using a respondent-driven sampling method. PRIMARY OUTCOME MEASURES: Proportion of both drug users who were ever tested for HIV and factors associated with HIV testing. RESULTS: Approximately 77% of IDUs and 46% of NIDUs were ever tested for HIV. The multivariate analysis revealed that having ever received drug treatment was positively associated with HIV testing among both IDUs (adjusted OR (AOR) 13.07; 95% CI 3.38 to 50.53) and NIDUs (AOR 3.58; 95% CI 1.38 to 9.24). IDUs who were married (AOR 0.24; 95% CI 0.06 to 0.94) and who injected at least twice daily (AOR 0.30; 95% CI 0.09 to 0.97) were less likely to undergo HIV testing. Among NIDUs, those who belonged to Shan (AOR 0.30; 95% CI 0.11 to 0.84) or Kachin (AOR 0.30; 95% CI 0.10 to 0.87) ethnicities were less likely to test for HIV. CONCLUSIONS: IDUs and NIDUs who have received drug treatment are more likely to test for HIV. Integrating HIV testing into drug treatment programmes alongside general expansion of HIV testing services may be effective in increasing HIV testing uptake among both IDUs and NIDUs in the Northern Shan State of Myanmar.

First hominoid from the Late Miocene of the Irrawaddy Formation (Myanmar).

For over a century, a Neogene fossil mammal fauna has been known in the Irrawaddy Formation in central Myanmar. Unfortunately, the lack of accurately located fossiliferous sites and the absence of hominoid fossils have impeded paleontological studies. Here we describe the first hominoid found in Myanmar together with a Hipparion (s.l.) associated mammal fauna from Irrawaddy Formation deposits dated between 10.4 and 8.8 Ma by biochronology and magnetostratigraphy. This hominoid documents a new species of Khoratpithecus, increasing thereby the Miocene diversity of southern Asian hominoids. The composition of the associated fauna as well as stable isotope data on Hipparion (s.l.) indicate that it inhabited an evergreen forest in a C3-plant environment. Our results enlighten that late Miocene hominoids were more regionally diversified than other large mammals, pointing towards regionally-bounded evolution of the representatives of this group in Southeast Asia. The Irrawaddy Formation, with its extensive outcrops and long temporal range, has a great potential for improving our knowledge of hominoid evolution in Asia.

A new primate from the Eocene Pondaung Formation of Myanmar and the monophyly of Burmese amphipithecids.

The family Amphipithecidae is one of the two fossil primate taxa from Asia that appear to be early members of the anthropoid clade. Ganlea megacanina, gen. et sp. nov., is a new amphipithecid from the late middle Eocene Pondaung Formation of central Myanmar. The holotype of Ganlea is distinctive in having a relatively enormous lower canine showing heavy apical wear, indicating an important functional role of the lower canine in food preparation and ingestion. A phylogenetic analysis of amphipithecid relationships suggests that Ganlea is the sister taxon of Myanmarpithecus, a relatively small-bodied taxon that has often, but not always, been included in Amphipithecidae. Pondaungia is the sister taxon of the Ganlea + Myanmarpithecus clade. All three Pondaung amphipithecid genera are monophyletic with respect to Siamopithecus, which is the most basal amphipithecid currently known. The inclusion of Myanmarpithecus in Amphipithecidae diminishes the likelihood that amphipithecids are specially related to adapiform primates. Extremely heavy apical wear has been documented on the lower canines of all three genera of Burmese amphipithecids. This distinctive wear pattern suggests that Burmese amphipithecids were an endemic radiation of hard object feeders that may have been ecological analogues of living New World pitheciin monkeys.

Proximal femoral anatomy of a sivaladapid primate from the late middle Eocene Pondaung formation (central Myanmar).

The postcranial anatomy of the Asian sivaladapid adapiforms is still virtually undocumented, whereas dental remains of these primates have been known for several decades. Little is known about their positional behavior as a result. In this article, we describe a partial left femur of a medium-sized primate preserving its entire proximal portion and a significant length of its shaft. This fossil was recently recovered from the fossiliferous locality of Thamingyauk in the late middle Eocene Pondaung Formation (central Myanmar). This femur is considered to pertain to the same individual as two tarsal elements (fragmentary talus and calcaneus) from the same locality (same location), and attributed to a medium-sized sivaladapid adapiform primate (Kyitchaungia takaii). This new postcranial element provides the first documentation of femoral anatomy among Sivaladapidae from Asia. The mechanical implications deriving from the musculoskeletal interpretation of this bone indicate an animal that probably engaged in a kind of active arboreal quadrupedalism with some degree of proficiency in leaping. Even though many musculoskeletal aspects suggest that branch walking and running were important parts of its locomotor repertoire, in other details it appears that relatively complex movements at the hip joint were actually possible and probably associated with climbing or some hindlimb suspensory activities.

Anatomy of the bony pelvis of a relatively large-bodied strepsirrhine primate from the late middle Eocene Pondaung Formation (central Myanmar).

Recent survey of the fossiliferous variegated mudstones of the PK1 locality (Sabapondaung) in the late middle Eocene Pondaung Formation (central Myanmar) has led to the recovery of a partial right innominate of a relatively large-bodied primate. Given its size and provenance, this bone probably belongs to the same individual represented by the NMMP 20 primate partial skeleton described previously from the same locality. The new fossil, which preserves the region around the acetabulum and the adjacent part of the ilium, clearly exhibits strepsirrhine rather than anthropoid affinities. This addition to our knowledge of the NMMP 20 partial skeleton allows us to reassess the different locomotor interpretations that have been proposed for this specimen. Aspects of pelvic morphology suggest that the NMMP 20 partial skeleton documents a primate that probably engaged in active arboreal quadrupedalism similar to that practiced by medium-sized Malagasy lemurids rather than lorislike slow moving and climbing. Given the conflicting phylogenetic signals provided by NMMP 39 (a talus showing anthropoid affinities) and NMMP 20 (a partial skeleton bearing adapiform affinities), it appears that two higher-level taxonomic groups of relatively large-bodied primates are documented in the Pondaung Formation. The recent discovery of two taxa of sivaladapid adapiforms from the Pondaung Formation indicates that the assumption that the NMMP 20 partial skeleton belongs to an amphipithecid can no longer be sustained. Instead, this specimen apparently documents a third large-bodied sivaladapid species in the Pondaung Formation.