Sunday, October 07, 2007

Pwof Ansanm's upcoming online auction

I'm the secretary of Pwof Ansanm, and I'm helping organize an upcoming online fund-raising auction to support educational initiatives in Haiti.

Who we are: from the mission statement at our site:

Pwof Ansanm is a network of educators who believe the role of education should be to empower individuals to improve their lives and communities. Pwof Ansanm was created in September 2004 as a non-profit, fully-volunteer organization registered in Pennsylvania. Pwof Ansanm promotes cooperative initiatives that address educational needs, and supports establishing community groups that assume responsibility for their own educational development. Pwof Ansanm Haiti was officially recognized in 2007 by the Ministry of Social Affairs. PAH will design projects independently but also evaluate, develop, and monitor programs that are supported by Pwof Ansanm. They will play a principal role in establishing links with the educational community in Haiti.

(From our latest newsletter)

"For the past few years, Pwof Ansanm has financed projects with grants specific for each project. All of the money raised has gone directly into support of those programs.

In the future, we are going to build a small financial reserve in order to stimulate new projects and to sponsor small initiatives without the need to write grants. This money will also provide support for operations of our sister organization, Pwof Ansanm Haiti.

We welcome items for donation to the auction---and certainly we would like you to participate in the fun part—--buying!

Please check our website in mid-October to see what marvelous items we will be putting up for auction."

We have some really nice pieces that people have donated to us, and Jesse (our web guy) is putting together a web site that will highlight them. More information here and at the Pwof Ansanm site as we finish putting it together.

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Wednesday, October 03, 2007

PHI conference: Hamish Fraser and EMRs for the developing world

One of the high points of the PHI conference I went to week before last was getting to meet Hamish Fraser and hear him talk about informatics tools to improve drug management and safety in developing countries. He's doing some very important work in Peru and Haiti, so his work has the potential to have a major impact for some of my colleagues in both countries. After his talk, I got to meet him and tell him how impressed I am with the work, especially given some particular infrastructural challenges in Haiti. He is a very gracious and knowledgeable man, and I hope we have the opportunity to collaborate at some point.

He noted that challenges in treating multiple-drug-resistant tuberculosis (MDR-TB) are just one of many obstacles facing an electronic medical record (EMR) system in Haiti. The effective use of drugs for that and other conditions depends on:

  • accurate diagnosis and case detection;
  • understanding appropriate treatments for the conditions in question;
  • accurate and appropriate prescribing for those conditions;
  • available drug supplies for those conditions;
  • correct and timely dispensing of those medications;
  • monitoring for adverse drug reactions and responding promptly when they are detected;
  • ensuring adherence to the medication regime and continuity of care.

The geography, economy, infrastructure (lack of good roads, for example), and other factors in Haiti make these goals challenging; what I hope to do in future research is to explore ways in which informatics can compensate for these challenges. Dr. Fraser and his research group are already taking the lead in developing applications to address these issues. For example, HIV treatment in Haiti requires, among other things, warehouse and pharmacy management systems, and Dr. Fraser's group is addressing this question using OpenMRS and collaborative development.

Rwanda Partners In Health has set up 6 clinics for HIV and other diseases, and an EMR is currently operational in all sites. They are now implementing a Haitian pharmacy system, and Partners In Health has been asked to set up an EMR system for all planned HIV treatment sites in the country. Additionally, they are scaling up the OpenMRS system to other sites and countries, and collaborating to develop a new design of an EMR system in developing countries. Current or future sites include Rwanda, Kenya, Lesotho, South Africa, Tanzania, Uganda, and Zimbabwe. Projects collaborating with OpenMRS include a lab system in Rwanda with HL7 linked to OpenMRS; the Baobab system in Malawi; the Africa Center, South Africa; Columbia University's Millennium Villages project; the D-TREE handheld system, South Africa; and Google's "Summer of Code" projects.

Important questions remain to research, of course:

  • how can we improve the use and safety of drugs in developing countries?
  • how can we assist in the meticulous observation of therapy which is required for these regimens?
  • what are the next steps in the develeopment of treatment strategies for MDR-TB, HIV/AIDS, and other chronic diseases?
  • we need more evaluations! For example:

    • effectiveness and impact of the information systems;
    • how well do the systems function in resource-poor areas?
    • how to ensure high-quality and timely data entry?
    • how can we reduce the time and effort required to use the systems?
    • and most important: through the use of these systems, can we show improvement in patient care?

Challenges include training; support and reliability of equipment and software; data management and quality control; and sustainability. He concluded by noting that many tools developed to improve drug use and management in the US can be adapted for use in developing countries. Additionally, the lack of redundant systems in these resource-poor areas only increases the importance of good information systems.

The questioners in the Q&A session afterward raised some very good points: One expressed heartfelt thanks for bringing up lesser-known, chronic diseases, which don't always get the attention that acute infectious diseases garner. He continued that he had heard a lot about implementing systems, but what about backing them up? Is there a way to utilize academic collaboration networks, given the risks onsite of tsunamis, hurricanes, etc.?

The answer was that the system consisted of a secure server with mirror servers and frequent backups. But an ethical question remained in resource allocation-—in case of disaster, is it more important to keep patient treatment going, or concentrate on sites to back up to? Obviously, that decision is a crucial one, and it highlights the importance of disaster recovery plans.

Another questioner raised the issue of information needs--there is a conflicting demand between keeping things simple with aggregate data vs. needing to keep more complicated individual data (which would be useful for, among other things, tracking data on developing drug resistance).

The panel answered that keeping clinical data straightforward is a high priority. They collect 6 discrete parameters for interoperability, but in a number of countries networks for surveillance are set up, which request or require aggregate data, which can be built from the data collected through their systems. Generally, the most important outcome to track is whether the patient got better, and for how long the patient was parasite-free. These are 2 pieces of information which should be routinely collected, starting with sentinel sites.


1: Wolfe BA, Mamlin BW, Biondich PG, Fraser HS, Jazayeri D, Allen C, Miranda J, Tierney WM. The OpenMRS system: collaborating toward an open source EMR for developing countries. AMIA Annu Symp Proc. 2006;:1146.

2: Fraser HS, Blaya J, Choi SS, Bonilla C, Jazayeri D. Evaluating the impact and costs of deploying an electronic medical record system to support TB treatment in Peru. AMIA Annu Symp Proc. 2006;:264-8.

3: Blaya J, Fraser HS. Development, implementation and preliminary study of a PDA-based tuberculosis result collection system. AMIA Annu Symp Proc. 2006;:41-5.

4: Choi SS, Jazayeri DG, Fraser HS. Optimizing data analysis tools to support healthcare workers in Peru. AMIA Annu Symp Proc. 2005;:923.

5: Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW, Szolovits P. Implementing electronic medical record systems in developing countries. Inform Prim Care. 2005;13(2):83-95.

6: Fraser HS, Jazayeri D, Nevil P, Karacaoglu Y, Farmer PE, Lyon E, Fawzi MK, Leandre F, Choi SS, Mukherjee JS. An information system and medical record to support HIV treatment in rural Haiti. BMJ. 2004 Nov 13;329(7475):1142-6.

7: Choi SS, Jazayeri DG, Mitnick CD, Chalco K, Bayona J, Fraser HS. Implementation and initial evaluation of a Web-based nurse order entry system for multidrug-resistant tuberculosis patients in Peru. Medinfo. 2004;11(Pt 1):202-6.

8: Szot A, Jacobson FL, Munn S, Jazayeri D, Nardell E, Harrison D, Drosten R, Ohno-Machado L, Smeaton LM, Fraser HS. Diagnostic accuracy of chest X-rays acquired using a digital camera for low-cost teleradiology. Int J Med Inform. 2004 Feb;73(1):65-73.

9: Jazayeri D, Farmer P, Nevil P, Mukherjee JS, Leandre F, Fraser HS. An Electronic Medical Record system to support HIV treatment in rural Haiti. AMIA Annu Symp Proc. 2003;:878.

10: Fraser HS, Jazayeri D, Mitnick CD, Mukherjee JS, Bayona J. Informatics tools to monitor progress and outcomes of patients with drug resistant tuberculosis in Peru.
Proc AMIA Symp. 2002;:270-4.

11: Fraser HS, Jazayeri D, Bannach L, Szolovits P, McGrath SJ. TeleMedMail: free software to facilitate telemedicine in developing countries. Medinfo. 2001;10(Pt 1):815-9.

12: Fraser HS, McGrath SJ. Information technology and telemedicine in sub-saharan Africa. BMJ. 2000 Aug 19-26;321(7259):465-6.

13: Fraser HS, Kohane IS, Long WJ. Using the technology of the World Wide Web to manage clinical information. BMJ. 1997 May 31;314(7094):1600-3.

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Monday, October 01, 2007

Yay, anonymous donor and The Edge of Glass!

(I'm going to have to change this slide, now that PZ has staked out Comic Sans as the "crank font"...

I need to re-do it for another reason, as well--Schutte did not discuss keratinization, a change in the cells' biochemical composition which lends a golden color to the cells. Durrant [1], by contrast, uses the color change associated with keratin as a marker for ovulation in the panda:

A second chromic shift was consistently observed 2 days prior to ovulation when keratinized (orange) cells replaced acidophils as the majority of vaginal cells.

So here's a wonderful example of modeling physiological processes across species: Schutte details the reproductive cycle of the dog, Durrant adapts that information and applies it to the panda, and then Durrant's group and ours uses that panda information to study other species of bear.)

Anyway, this is a presentation slide that I adapted (animated, colored) from Schutte 1967 [2,3,4] for a talk on using informatics to aid in the reproduction of endangered species at the 2004 American Veterinary Medical Association conference:

What you are seeing, as you read left to right, is the change over time in the shape and color of the vaginal epithelial cells, collected by swabbing the animal. Shape changes (from more round to more irregular and from a high nucleus-to-cell size ratio to a much lower one, approaching or reaching zero in some cases), and color changes between pink/red (acidophilic) and blue (basophilic) can be seen as the cycle progresses. Although the hormone level peaks and the white and red blood cells (leukocytes and erythrocytes) are shown as well, we'll ignore those for the moment to concentrate on the changes in the colored cells in the middle of the diagram.

With a break in between, the cycle resumes at the left, and the whole process is repeated over and over again through the animal's reproductive life.

The important take-away points from this slide are the irregular borders and small nuclei of the aging cell, and the colors blue and pink (depicted above), and golden (which is also significant in pandas, but which Schutte did not address in dogs in his work).

So keeping those factors in mind, you can see why I was practically dumbstruck when I walked into a glass art studio in Fremont (a Seattle neighborhood) and noticed the piece by James Curtis titled "Little Bang":

I mean, it's all there! Large, irregular cell borders, tiny nuclei, and pink (cranberry), blue (teal), and golden color. Even the rack on which it is mounted looks like a graph over time of a cycle. I swear, if I had commissioned the artist to render mature vaginal epithelial cells in glass, he could not have carried it out more faithfully.

A huge shout-out to James and his assistant Tara for patiently working with me while I arranged financing and donation of the work to our sun bear reproductive project for auction at a later date. If you're looking for glass art, I would recommend The Edge of Glass in Seattle unconditionally for their quality, their vision, and their customer service.

And to our anonymous donor, who prefers to remain behind the scenes to put the work at the forefront, our deepest gratitude and appreciation for your help for the bears. We will keep you posted on the progress of the project.

UPDATE: I forgot, before I published this post, to mention that James told me he probably will not use the teal again, or if he does, it won't be very often--it is simply so hard to work with that it's not practical. So the bears and I did indeed get very lucky to get in there before someone else bought the piece, and we would never had known about it. I thank Mr. thalarctos for deciding to surprise me with a drop-in visit there; it worked out so much more beautifully than I could have predicted.


[1] Durrant B, Czekala N, Olson M, Anderson A, Amodeo D, Campos-Morales R, Gual-Sill F, Ramos-Garza J. Papanicolaou staining of exfoliated vaginal epithelial cells facilitates the prediction of ovulation in the giant panda. Theriogenology. 2002 Apr 15;57(7):1855-64.

[2] Schutte AP. Canine vaginal cytology. I. Technique and cytological morphology. J Small Anim Pract. 1967 Jun;8(6):301-6. No

[3] Schutte AP. Canine vaginal cytology. II. Cyclic changes. J Small Anim Pract. 1967 Jun;8(6):307-11.

[4] Schutte AP. Canine vaginal cytology. III. Compilation and evaluation of cellular indices. J Small Anim Pract. 1967 Jun;8(6):313-7.

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