Digitalization of medical records: pearls and perils

Digitalization of medical records

 

Nitin K Sethi, MD

 

            No one would argue that digitalization of medical records represents a step in the right direction. The benefits are indeed many to reap. Digital medical records shall ensure rapid communication among caregivers and the current restriction of geography shall be overcome. A resident of Manhattan, who happens to fall ill in San Diego while on a business meeting, can rest assured that the doctor who is taking care of him in the ER shall have access to his medical history and medication list. He would know which drug to avoid based on previous history of drug allergies. Medical errors shall be avoided and costly investigations needed not be repeated. Would it potentially save a life? Yes it would. A comatosed patient brought to the ER after a motor vehicle accident cannot speak and give a history. Doctors waste precious moments trying to ascertain history from family and there are many times when we cannot track any family member to get relevant medical and surgical history. At times this lack of history and delay leads to potentially life saving treatments been denied to the patient. A case in point is the administration of a clot bursting drug to a patient who presents to the ER with an acute stroke. Unless we can document that the patient is not on any blood thinners, this therapy cannot be administered.

            Digital medical records shall also improve physician to physician communication and this shall be of tremendous benefit to patients with chronic disorders such as multiple sclerosis whose care involves multidisciplinary specialties. Care would be more coordinated and I think a win-win situation for all involved and I mean all. Patients would be treated as a whole and not in parts where the right hand does not know what the left hand does. Medical errors shall be avoided; cost of care would decrease benefiting doctors as well as insurance carriers.

            But just like a rose comes with thorns so does the good idea of digital medical records. It cannot succeed unless it is implemented in whole. Every hospital whether state or private run and every doctor clinic would have to be mandated to implement it otherwise like other bright ideas gone sour, we risk having a fractured system with some institutions having digital medical records and others paper records. Digitalization of medical records is not going to be cheap and we rather not add to our already inflated medical budget with a half hearted effort.

 

An interview about Multiple Sclerosis

“Merely me” is a mother, a writer and a staunch MS patient advocate. I have had the good fortune of getting to know her recently. She has an amazing drive and feels strongly about issues related to multiple sclerosis. She recently interviewed me.

Here is the link to her site and the interview. I hope you find the information presented there helpful.

http://www.healthcentral.com/multiple-sclerosis/c/73302/54272/doctor

Personal Regards,

Nitin Sethi, MD

Multiple Sclerosis-a question and an answer

 One of readers emailed me this question. My response to it follows.

Riddler on October 17, 2008 said: Edit Link

Hello Dr,

I am a 28 asian/indian female. I was brought up in India for large part of my file.
I had symptoms of blind spots in my vision sometime back. The condition persisted for 2 days before I scheduled an appointment with my opthamalogist. He suspected that I have optic nueritis and advised me for a MRI. Now the lab technician says that I have a few lesions in my brain and asked me to consult a nuerologist. I have a pending appointment. My eye became completely normal in about 10 days from onset. By googling I found that it might be a case of MS.

Is it always the case optic nueritis + MRI lesions = MS? Is there anything else I should be looking at? I’ve had problems of vitamin deficiencies in the past. I have had some tongue rashes, gastro problems. Nothing serious but minor issues though.

Thanks,
Riddler

Dear Riddler,

                                      patients who have optic neuritis usually do not complain of blind spots, rather they have acute/sudden loss of vision (usually in one eye, though in a condition called neuromyelitis optica they may have optic neuritis in both eyes). This condition may be painful (complaint of pain in the eye). Not all patients who have optic neuritis have multiple sclerosis. There can be many other causes of optic neuritis namely other infectious and inflammatory conditions. Patients who present with optic neuritis and are in the right age group (eg a woman in her 20s or 30s presenting with optic neuritis), need to be worked up for multiple sclerosis. Usually we order a MRI brain, to see if there is evidence of multiple sclerosis (read my posts on white matter lesions in the MRI brain of MS patients at http://braindiseases.info). As I have stated repeatedly, not all white matter lesions on the MRI represent multiple sclerosis.

In answer to your question, yes some vitamin deficiencies can cause blind spots and lesions in the brain. My advise to you would be to see a neurologist, the diagnosis of optic neuritis can be confirmed with the aid of certain tests like visual evoked potentials (VEP). Then the MRI can be interpreted in the right context.

Personal Regards,

Nitin Sethi, MD

White matter lesions on MRI–a question and some answers

I thank one of my readers Sandy for writing in.  Sandy asks some important questions. As a lot of you may be dealing with some of the same issues as her, I am reproducing her question here. My answers to her query follow.

Again thank you Sandy for writing in.

Sandy

Dear Dr.

In june I experienced some very unusual headaches that felt think electrical shocks throughout my head. One night I experienced the worst headache of my life in my forehead only. It lasted all night and in the morning it was better; however I experienced dizziness and if I bent over a swell of pain would radiate through my head. A week later I experienced an eye problem and was told that it was uveitis. Because uveitis can be caused by a virus or autoimmune problem, I immediately began testing for an autoimmune problem. During this testing I continued to experiece overall nerve pain in by head (forehead, temple, back of head) as well as neck pain, should nerve pain through fingers, neck, ankels), joint & chest pain. The only positive test result showed a high ANA test of 1:640 but all other blood tests(c-reactive protein, RF, Sed Rad, SM etc..) were normal. I also had an MRI and the radiologist noted several tiny foci white matter in the frontal lobe area. He indicated that it is may or may not be of clinical significane but could be small vessel ischemia disease or possible dymlienation. I wonder if there is a correlation to the several headache I had in my forehead with the MRI results. My neurologist initially said I had occpital headaches and is normally caused by a pinched nerve; but after receiving this MRI, I don’t think he has it right. I feel the headaches and vision problems along with the other symtoms correlate together. Should I be concerned about this MRI. I don’t feel that this is MS because I’m not having muscular/walking issues; but greatly concerned that if these headaches continue, cognitive problems could occur. Your opinion would be greatly appreciated.

From MRI white matter lesions: does it represent MS?, 2008/09/26 at 2:24 PM

 

Dear Sandy,

                      thank you for writing in. Your case history is intriguing, since I do not have all the details my assessment is severly limited.  I can though tell you that white matter lesions are commonly seen when patients undergo a MRI study of the brain. Some of the times these white matter lesions (also referred to as white matter hyperintensities (WMH), this is because they appear as bright white spots on the MRI) are incidental findings and may have nothing to do with the reason the MRI was done in the first place. Let me explain. Lets assume you come to see me since you have being lately experiencing headaches. I order an MRI because I want to rule out a brain tumor. MRI result comes back. There is no brain tumor but incidentally note is made of several scattered white matter hyperintense lesions. Likely in the case I describe above, the WMHs are incidental findings and not the cause of the patient’s severe headaches.

So what do these white matter lesions represent? Many diseases can cause white matter lesions in the brain MRI.  One of the diseases usually mentioned in MRI reports is multiple sclerosis. Patients rightly get scared that they may have MS. While multiple sclerosis is characterized by white matter lesions (we call them plaques in the case of MS) which are scattered in the brain, I want to re-emphasize that not all white matter lesions represent MS (see my website for more details http://braindiseases.info). In the case of MS, the plaques are scattered in the brain in a particular way. Moreover if you do not have any signs or symptoms of MS (your examination is normal), more than likely the white matter lesions do not represent MS. The diagnosis of MS is clinical, at times supplemented by tests like MRI brain, CSF/ spinal fluid examination and evoked potentials.

A lot of work has been done to determine the significance of white matter lesions. The thinking now is that they represent ischemia (lack of blood flow) in the small blood vessels of the brain. Hence they are also at times referred to as ischemic small vessel disease. Hence these lesions are more commonly seen in the MRI of patients who have cerebrovascular risk factors like hypertension, diabetes and high cholesterol as well those that smoke. Their incidence increases as we age (meaning you are more likely to see them on the MRI of someone who is 60 and above rather than someone who is in his 20’s).

They have been reported in the MRI of patients who suffer for migraine. The reason they are more commonly seen in migraine patients is again not fully elucidated but the thinking is that migraine is due to vascular causes and hence WMHs are more common in these patients.

While I cannot comment of your case in particular, you have a positive ANA though rest of the autoimmune markers are negative and your ESR is low. I would rule out the usual suspects, vasculitis though remains in the differential and it would be reasonable to make sure you do not have any underlying vasculitic etiology.

Your last question is important. Though there is no direct correlation between the extent of WMHs in the brain and the development of cognitive decline, as I stated earlier they become more common as we age. People who have extensive white matter disease in their MRI frequently do exhibit cognitive deficts when carefully tested for. Whether this represents a form of vascular dementia is not clear.

I would advise you to follow with your PMD and neurologist. They would be the best people to guide further diagnostic workup and treatment.

Personal Regards,

Nitin Sethi, MD

Few Multiple Sclerosis questions and their answers

Nitin K Sethi, MD

Assistant Professor of Neurology

NYP-Weill Cornell Medical Center

New York, NY 10065

One of my readers Lisa asked me some very specific MS questions. Since I feel these questions shall be on many MS patients minds I am reproducing them here. Here are the questions followed by my answers. Thank you Lisa!!!

  1. Lisa on September 17, 2008 said:

Hi, I have enjoyed reading the information you posted. I have a few questions of my own:

At this point, I have an MRI with 8 lesions, one possibly of which is tumefactive MS, a postive LP for oligoclonal bands, and my neurologist has diagnosed me with “clinically isolated syndrome”…not full blown MS at this point, but still wants to begin treatment.

1. Is tumefactive MS considered more fatal or harder to treat than “regular” MS?

2. How many oligoclonal bands are needed for a low amount? High amount? My report states greater than 3 bands. Why is there not a specific number given?

3. I have been given the choice between Rebif and Copaxone. Which is the better treatment?

  1. 7 braindiseases on September 18, 2008 said:

Dear Lisa,
thank you for writing in. You ask some very specific questions and that is what I shall attempt to answer. I am not sure why your doctor has stil labelled you as a clinically isolated syndrome (likely it is because you have had only one clinical attack suggestive of MS). Your MRI though does show dissemination of the disease in space (you can read more about the clinical diagnosis of MS on my website
http://braindiseases.info) and you have more than 3 oligoclonal bands in your CSF. Now to answer your first question. Some patients have large sized demyelinating plaques (lesions) on their MRI. This is commonly referred to as tumefactive MS (because on the MRI, the lesion is large and resembles a tumor more which it has to be differentiated). There is some data to suggest that MS patients with tumefactive disease have a more aggressive disease course. Though I have to add that this data is not robust.
Oligoclonal bands are frequently present in the CSF of MS patients. Here I have to add that oligoclonal bands can be seen in many other conditions other than MS hence one has to make sure that they are present only in the CSF and not in the blood (In MS these bands are produced intrathecally meaning present only in CSF but not in blood). One study suggested that low or absent number of oligoclonal bands in the cerebrospinal fluid at the time of diagnosis predicts a better prognosis. However quantification of oligoclonal bands in the CSF remains an insensitive prognostic indicator and hence should not be used to influence decisions regarding treatment.
Now to your third question. There is some evidence to suggest that higher dose interferon (Betaseron/ Rebif) are more effective as compared to lower dose interferon. The interferons as well as Copaxone are recommened for initial treatment of relapsing remitting MS. Most of the times it is the patient’s lifestyle, easy of administration and side-effect profile which determines the choice between them.
I hope that helps you out and feel free to write again. I wish you the best.


Personal Regards,
Nitin Sethi, MD

Heat sensitivity in patients with MS

I wanted to just touch on the subject of heat sensitivity in multiple sclerosis patients. MS patients are more sensitive to heat/ temperature as compared to non MS patients. It has been seen they do “poorly” whenever their body temperature is elevated. So when MS patients have fever, they become weaker and their neurological deficits become more prominent e.g. more blurring of vision, diplopia, ataxia and cerebellar dysfunction. Thus infections such as pneumonia and urinary tract infections (UTI) warrant to be aggressively treated with anti-pyretics and antibiotics.

Why does this occur? Well the thinking is that as the temperature of the body increases, it promotes cross-talk among the demyelinated axons and also leads to conduction blocks (block in the conduction of impulses in the neurons). This exacerbates preexisting neurological deficits.

So it follows that MS patients do better in colder environments as compared to warmer places.  Better in winter as compared to the heat of summer. Keeping the ambient temperature of your house a few degrees below “normal” may be worthwhile though there is no scientific data to back this claim.

 

Nitin Sethi, MD

Spinal cord lesions in MS

Multiple sclerosis is a demyelinating disease of the central nervous system (demyelinating because the disease is characterized by the loss of the myelin sheath around the axons of the nerve cells). As I have stated in my previous posts on MS (see http://braindiseases.info for all the previous posts on MS), the disease is characterized by plaques which are disseminated in space and time.

Most of these plaques (demyelinating lesions of MS) are seen in the brain but a few patients have what is loosely called spinal MS or rather MS in which the plaques are more commonly seen in the spinal cord (remember the spinal cord is a part of the central nervous system). These patients with spinal MS present with slightly different clinical signs and symptoms. They may present with what is called transverse myelitis (this is an involvement of the spinal cord usually at the cervical or thoracic level). Transverse myelitis can be devastating because all the descending motor fibers from the brain and the ascending sensory tracks are packed in the small diameter of the spinal cord. So any involvement of the spinal cord has the potential to affect all these tracks. Depending upon the level of cord involvement patients may have either weakness of just the legs (paraparesis or paraplegia) or all the four limbs may be involved (quadriparesis or quadriplegia). Usually the bladder and bowel are involved too and patients may have complaints of urinary incontinence. Sexual dysfunction is also commonly reported (erectile dysfunction in males, see my previous post on it).

As the involvement of the brain is less, these patients are relatively well preserved cognitively and may not have prominent cerebellar findings.

Spinal involvement in MS is treated in much the same way as other forms of MS. Your doctor may use a course of intravenous corticosteroids if you present to the hospital with acute transverse myelitis. Immuno modulating drugs like interferons may later be prescribed.

Personal Regards,

Nitin Sethi, MD

Erectile dysfunction-some neurological causes

I thought I would discuss some neurological causes of erectile dysfunction and decreased libido. There are many neurological diseases which are associated with erectile dysfunction and may also result in decreased libido. One of the most common is diabetic autonomic neuropathy. Diabetic patients especially those who have autonomic neuropathy (dysautonomia) frequently have erectile dyfunction. Supprisingly many do not volunteer this information, unless their doctor asks about it. They may complain of other symptoms of neuropathy like pain and numbess in their hands and feet but may not volunteer the history that they are having erectile dysfunction. Many patients do not realize that their erectile problems are a part and parcel of their uncontrolled diabetes.

Erectile problems and decrease libido is also frequently seen in patients who have multiple sclerosis. Fortunately this aspect of MS is now been given increasing recognition by doctors and a discussion is initiated with the patient at some stage of their treatment. Women with MS may have complaints of decreased vaginal lubrication, loss of vaginal muscle tone and diminished clitoral engorgement.
All this can lead to a decrease or loss of sex drive. Decreased or unpleasant genital sensations may lead to a diminished capacity for orgasm. Men with MS experience  erectile dysfunction and a decrease in or loss of ejaculatory force or frequency.

Erectile dysfunction and sexual difficulties are also a part and parcel of certain neurodegenerative conditions like multi system atrophy especially a syndrome called Shy Drager Syndrome in which autonomic failure is prominent. Parkinsons disease and patients with degenerative dementias may also have some of these problems. In these patients the cause is usually multifactorial.

Patients with epilepsy also frequently have sexual dysfunction. Again the causes are multifactorial but one important reversible cause is drug side-effects. Some anti-epileptic drugs and antidepressants frequently cause sexual dysfunction as a side-effect.

The good news is that sexual dysfunction is now more readily recognized as a part and parcel of certain neurological disorders. Neurologists are nowdays more adept in asking patients about it. It is important that patients volunteer information if they are experiencing sexual dysfunction as many of the causes are treatable. Drugs with sexual dysfunction as a side-effect can be stopped and replaced with other drugs. Also some of the symptoms can be ameriolated by using medications like sildenafil (Viagra).

Personal Regards,

Nitin Sethi, MD

Is it or is it not multiple sclerosis?

Since my posts on multiple sclerosis are getting many hits from readers, I thought that I would in this post describe how a definitive diagnosis of MS is made.

First and foremost, a definitive diagnosis of MS can be made just clinically without any other imaging studies like MRI or the need for invasive tests like lumbar puncture (spinal tap). How you may ask?

Well if by history you have had two attacks suggestive of MS which are disseminated in time and space, then a definitive diagnosis of MS can be made. Let me explain this in simple language. Lets assume you go to your doctor because you have been having numbness in your right arm. Your doctor examines you and finds that apart from sensory loss in the right arm, you have other examination findings such as you have ataxia (your gait is off and unsteady), you have incoordination and tremor in your right arm, your eyes do not move well and you have what we call internuclear opthalmoplegia. Hmm sorry for all that medical jargon, let me try to make it more simple. What I am trying to say that your examination findings are suggestive of not one but multiple sites of pathology in your brain.

Numbness right arm localizes to the sensory cortex on the left side of your brain.

Ataxia might be due to midline cerebellar problem

Right arm tremor localizes to the right cerebellum (cerebellar pathways are double crossed in the brain)

The eye findings and internuclear opthalmoplegia localizes to the midbrain.

So you have signs that whatever your disease is it is disseminated in space (SPACE AS IN DISSEMINATED IN DIFFERENT  PARTS OF THE BRAIN). Your findings cannot be explained by one single lesion rather by multiple small lesions.

So you have met the first criteria to make a definitive diagnosis of MS-dissemination in space. (OF COURSE DISSEMINATION IN SPACE SHALL ALSO BE CLEARLY SHOWN IF YOU DO A MRI SCAN)

 Now how do we prove you have dissemination in time?  Well that is done by history. Lets assume your doctor now asks you ” Miss Smith have you ever had a problem with your eye before? Did you ever lose vision in one eye?”

Miss Smith: ” Now that you ask doctor Sethi, yes. When I was 18, I had an episode where I had pain in my left eye and lost vision rather abruptly. By the time I saw my doctor, it had started to improve by itself and I did not think much of it.”

Viola!!! here the history is telling you that Miss Smith has in fact had dissemination in time. Likely she had an attack of optic neuritis when she was 18 which had resolved by itself.

So as a doctor examining Miss Smith, I now know that her disease is disseminated in time (she has had attacks in the past) and also in space (from my examination findings I know that she likely has multiple lesions in the brain, only then I can explain all her findings).

I DO NOT NEED ANY ADDITIONAL TESTS TO MAKE A DIAGNOSIS OF MS. SHE HAS HAD 2 ATTACKS DISSEMINATED IN TIME AND SPACE.

Of course as part of her management I would do a MRI study of the brain and some doctors might still do a lumbar puncture. 

 Additional tests like MRI brain, spinal tap and evoked potentials (visual and somatosensory evoked potential) are needed when either of the above 2 is missing. Either Miss Smith has had just one clinical attack or her examination finding are suggestive of one lesion.

Nitin Sethi, MD

Cannabis use in patients with multiple sclerosis

Just read a study in Neurology about the effects of marijuana in patients with multiple sclerosis. It seems that MS patients who smoke marijuana have more cognitive dysfunction and mood disorders as compared to MS patients that do not. MS patients may be smoking marijuana recreationally or they may be using it to get rid of tingling and other paraesthesias.

Multiple sclerosis itself causes cognitive problems and if patients smoke marijuana it seems they compound them. With the limited data available to us currently, it is probably wise that patients with multiple sclerosis avoid smoking marijuana.

Nitin Sethi, MD