Discussion of “Evidence-based Health Informatics: How Do We Know What We Know?”

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper “Evidence-based Health Informatics: How Do We Know What We Know?” written by Elske Ammenwerth [1]. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Ammenwerth paper. In subsequent issues the discussion can continue through letters to the editor.

With these comments on the paper “Evidence-based Health Informatics: How do we know what we know?”, written by Elske Ammenwerth [1], the journal seeks to stimulate a broad discussion on the challenges of evaluating information processing and information technology in health care. An international group of experts has been invited by the editor of Methods to comment on this paper. Each of the invited commentaries forms one section of this paper.

Discussion of “Biomedical Infor -matics: We Are What We Publish”

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commenta -ries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

Optimizing Crystal Size of Photosystem II by Macroseeding: Toward Neutron Protein Crystallography

Photosystem II (PSII) catalyzes the photo-oxidation of water to molecular oxygen and protons. The water splitting reaction occurs inside the oxygen-evolving complex (OEC) via a Mn₄CaO₅ cluster. To elucidate the reaction mechanism, detailed structural information for each intermediate state of the OEC is required. Despite the current high-resolution crystal structure of PSII at 1.85 Å and other efforts to follow the structural changes of the Mn₄CaO₅ cluster using X-ray free electron laser (XFEL) crystallography in addition to spectroscopic methods, many details about the reaction mechanism and conformational changes in the catalytic site during water oxidation still remain elusive. In this study, we present a rarely found successful application of the conventional macroseeding method to a large membrane protein like the dimeric PSII core complex (dPSIIcc). Combining microseeding with macroseeding crystallization techniques allowed us to reproducibly grow large dPSIIcc crystals with a size of ~3 mm. These large crystals will help improve the data collected from spectroscopic methods like polarized extended X-ray absorption fine structure (EXAFS) and single crystal electron paramagnetic resonance (EPR) techniques and are a prerequisite for determining a three-dimensional structure using neutron diffraction.

Structural insights into the light-driven auto-assembly process of the water-oxidizing Mn4CaO5-cluster in photosystem II

In plants, algae and cyanobacteria, Photosystem II (PSII) catalyzes the light-driven splitting of water at a protein-bound Mn₄CaO₅-cluster, the water-oxidizing complex (WOC). In the photosynthetic organisms, the light-driven formation of the WOC from dissolved metal ions is a key process because it is essential in both initial activation and continuous repair of PSII. Structural information is required for understanding of this chaperone-free metal-cluster assembly. For the first time, we obtained a structure of PSII from Thermosynechococcus elongatus without the Mn₄CaO₅-cluster. Surprisingly, cluster-removal leaves the positions of all coordinating amino acid residues and most nearby water molecules largely unaffected, resulting in a pre-organized ligand shell for kinetically competent and error-free photo-assembly of the Mn₄CaO₅-cluster. First experiments initiating (i) partial disassembly and (ii) partial re-assembly after complete depletion of the Mn₄CaO₅-cluster agree with a specific bi-manganese cluster, likely a di-µ-oxo bridged pair of Mn(III) ions, as an assembly intermediate.

DOI:http://dx.doi.org/10.7554/eLife.26933.001

Drop-on-demand sample delivery for studying biocatalysts in action at X-ray free-electron lasers

X-ray crystallography at X-ray free-electron laser sources is a powerful method for studying macromolecules at biologically relevant temperatures. Moreover, when combined with complementary techniques like X-ray emission spectroscopy, both global structures and chemical properties of metalloenzymes can be obtained concurrently, providing insights into the interplay between the protein structure and dynamics and the chemistry at an active site. The implementation of such a multimodal approach can be compromised by conflicting requirements to optimize each individual method. In particular, the method used for sample delivery greatly affects the data quality. We present here a robust way of delivering controlled sample amounts on demand using acoustic droplet ejection coupled with a conveyor belt drive that is optimized for crystallography and spectroscopy measurements of photochemical and chemical reactions over a wide range of time scales. Studies with photosystem II, the phytochrome photoreceptor, and ribonucleotide reductase R2 illustrate the power and versatility of this method.

Structure of photosystem II and substrate binding at room temperature

Light-induced oxidation of water by photosystem II (PS II) in plants, algae and cyanobacteria has generated most of the dioxygen in the atmosphere. PS II, a membrane-bound multi-subunit pigment protein complex, couples the one-electron photochemistry at the reaction centre with the four-electron redox chemistry of water oxidation at the Mn₄CaO₅ cluster in the oxygen-evolving complex (OEC). Under illumination, the OEC cycles through five intermediate S-states (S₀ to S₄), in which S₁ is the dark-stable state and S₃ is the last semi-stable state before O-O bond formation and O₂ evolution. A detailed understanding of the O-O bond formation mechanism remains a challenge, and will require elucidation of both the structures of the OEC in the different S-states and the binding of the two substrate waters to the catalytic site. Here we report the use of femtosecond pulses from an X-ray free electron laser (XFEL) to obtain damage-free, room temperature structures of dark-adapted (S₁), two-flash illuminated (2F; S₃-enriched), and ammonia-bound two-flash illuminated (2F-NH₃; S₃-enriched) PS II. Although the recent 1.95 Å resolution structure of PS II at cryogenic temperature using an XFEL provided a damage-free view of the S₁ state, measurements at room temperature are required to study the structural landscape of proteins under functional conditions, and also for in situ advancement of the S-states. To investigate the water-binding site(s), ammonia, a water analogue, has been used as a marker, as it binds to the Mn₄CaO₅ cluster in the S₂ and S₃ states. Since the ammonia-bound OEC is active, the ammonia-binding Mn site is not a substrate water site. This approach, together with a comparison of the native dark and 2F states, is used to discriminate between proposed O-O bond formation mechanisms.

Systematic analysis of protein-detergent complexes applying dynamic light scattering to optimize solutions for crystallization trials

Detergents are widely used for the isolation and solubilization of membrane proteins to support crystallization and structure determination. Detergents are amphiphilic molecules that form micelles once the characteristic critical micelle concentration (CMC) is achieved and can solubilize membrane proteins by the formation of micelles around them. The results are presented of a study of micelle formation observed by in situ dynamic light-scattering (DLS) analyses performed on selected detergent solutions using a newly designed advanced hardware device. DLS was initially applied in situ to detergent samples with a total volume of approximately 2 µl. When measured with DLS, pure detergents show a monodisperse radial distribution in water at concentrations exceeding the CMC. A series of all-trans n-alkyl-β-D-maltopyranosides, from n-hexyl to n-tetradecyl, were used in the investigations. The results obtained verify that the application of DLS in situ is capable of distinguishing differences in the hydrodynamic radii of micelles formed by detergents differing in length by only a single CH2 group in their aliphatic tails. Subsequently, DLS was applied to investigate the distribution of hydrodynamic radii of membrane proteins and selected water-insoluble proteins in presence of detergent micelles. The results confirm that stable protein-detergent complexes were prepared for (i) bacteriorhodopsin and (ii) FetA in complex with a ligand as examples of transmembrane proteins. A fusion of maltose-binding protein and the Duck hepatitis B virus X protein was added to this investigation as an example of a non-membrane-associated protein with low water solubility. The increased solubility of this protein in the presence of detergent could be monitored, as well as the progress of proteolytic cleavage to separate the fusion partners. This study demonstrates the potential of in situ DLS to optimize solutions of protein-detergent complexes for crystallization applications.

Discussion of "Biomedical informatics: we are what we publish"

This article is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Biomedical Informatics: We Are What We Publish", written by Peter L. Elkin, Steven H. Brown, and Graham Wright. It is introduced by an editorial. This article contains the combined commentaries invited to independently comment on the Elkin et al. paper. In subsequent issues the discussion can continue through letters to the editor.

[Satisfaction with dental care from the patient's perspective - the dental-ZAP-V1]

BACKGROUND

Patient satisfaction is a central topic in quality management in outpatient dental care. The ZAP questionnaire was validated to explore patient satisfaction in general and specialist outpatient settings. This study aims at assessing the psychometric properties of the ZAP in dental care.

METHODS

A minimally modified version of the ZAP consisting of 4 domains (office organisation, cooperation, interaction, information) was administered in personal interviews to a population-based sample. Descriptive, exploratory and confirmatory psychometric analyses were conducted with random subsets of the study sample.

RESULTS

The study population comprised 1 773 subjects with at least one dental visit during their lifetime (mean age=50 years, female=51.6%). The exploratory factor analysis identified 3 subscales (office organisation, interaction, information). Based on these results, items of the subscale "cooperation" were excluded from further analyses. The remaining items had a medium difficulty of 0.75, all item-total-correlations were above 0.4. Missing values ranged between 2.3% and 28.7%. Cronbach's alpha ranged between 0.79 and 0.95. After introduction of 3 residual correlations, the confirmatory factor analyses reached a good model fit (TLI: 0.97; CFI: 0.97, RMSEA: 0.06). Partial standardised factor loadings ranged between 0.77 and 0.87. The 3 latent factors were highly correlated. There was a positive correlation between the 3 subscales and global patient satisfaction with the dentist.

CONCLUSION

The psychometric assessment can be used in the 3 modified subscales (office organisation, interaction, and information) to assess patient satisfaction with dental care. To assess dentist's competence in relation to dental anxiety and pain as well as shared decision making new scales specific to dental care should be explored.

Dying to give birth: the Pakistan Liaison Committee's strategies to improve maternal health in Pakistan

Pakistan has one of the worst maternal mortality ratios worldwide: 260-490 women die for every 100,000 live births in Pakistan. The Pakistan Liaison Group (PLG) was formed to work with and through the international office of the Royal College of Obstetricians and Gynaecologists (RCOG). It works with the RCOG representative committee in Pakistan to improve the health of women. It aims to contribute to improving maternal morbidity and mortality through strategies directed at improving the education and training of health professionals. In addition, the PLG aims to promote changes in the legislature to allow for the notification of maternal deaths so that accurate figures can be obtained, and so that health parameters can be accurately assessed and, in the long term, a confidential enquiry into maternal deaths can be initiated.

Biomedical and Health Informatics Education and Research at the Information Technology Institute in Egypt

During the last decade, Egypt has experienced a revolution in the field of Information and Communication Technology (ICT) that has had a corresponding impact on the field of healthcare.

Since 1993, the Information Technology Institute (ITI) has been leading the development of the Information Technology (IT) professional training and education in Egypt to produce top quality IT professionals who are considered now the backbone of the IT revolution in Egypt. For the past five years, ITI has been adopting the objective of building high caliber health professionals who can effectively serve the ever-growing information society.

Academic links have been established with internationally renowned universities, e.g., Oregon Health and Science University (OHSU) in US, University of Leipzig in Germany, in addition those with the Egyptian Fellowship Board in order to enrich ITI Medical Informatics Education and Research.

The ITI Biomedical and Health Informatics (BMHI) education and training programs target fresh graduates as well as lifelong learners. Therefore, the program’s learning objectives are framed within the context of the four specialization tracks: Healthcare Man- agement (HCM), Biomedical Informatics Research (BMIR), Bioinformatics Professional (BIP), and Healthcare Professional (HCP). The ITI BMHI research projects tackle a wide-range of current chal- lenges in this field, such as knowledge management in healthcare, providing tele-consultation services for diagnosis and treatment of infectious diseases for underserved regions in Egypt, and exploring the cultural and educational aspects of Nanoinformatics.

Since 2006, ITI has been positively contributing to de- velop the discipline of BMHI in Egypt in order to support improved healthcare services .

Biomedical and health informatics education and research at the Information Technology Institute in Egypt

OBJECTIVES

During the last decade, Egypt has experienced a revolution in the field of Information and Communication Technology (ICT) that has had a corresponding impact on the field of healthcare. Since 1993, the Information Technology Institute (ITI) has been leading the development of the Information Technology (IT) professional training and education in Egypt to produce top quality IT professionals who are considered now the backbone of the IT revolution in Egypt. For the past five years, ITI has been adopting the objective of building high caliber health professionals who can effectively serve the ever-growing information society.

METHODS

Academic links have been established with internationally renowned universities, e.g., Oregon Health and Science University (OHSU) in US, University of Leipzig in Germany, in addition those with the Egyptian Fellowship Board in order to enrich ITI Medical Informatics Education and Research.

RESULTS

The ITI Biomedical and Health Informatics (BMHI) education and training programs target fresh graduates as well as life-long learners. Therefore, the program's learning objectives are framed within the context of the four specialization tracks: Healthcare Management (HCM), Biomedical Informatics Research (BMIR), Bioinformatics Professional (BIP), and Healthcare Professional (HCP). The ITI BMHI research projects tackle a wide-range of current challenges in this field, such as knowledge management in healthcare, providing tele-consultation services for diagnosis and treatment of infectious diseases for underserved regions in Egypt, and exploring the cultural and educational aspects of Nanoinformatics.

CONCLUSION

Since 2006, ITI has been positively contributing to develop the discipline of BMHI in Egypt in order to support improved healthcare services.

A toxicological evaluation of inhaled solid lipid nanoparticles used as a potential drug delivery system for the lung

Inhalation is a non-invasive approach for both local and systemic drug delivery. This study aimed to define the therapeutic window for solid lipid nanoparticles (SLNs) as a drug delivery system by inhalation from a toxicological point of view. To estimate the toxic dose of SLNs in vitro, A549 cells and murine precision-cut lung slices (PCLS) were exposed to increasing concentrations of SLNs. The cytotoxic effect of SLNs on A549 cells was evaluated by MTT and NRU assays. Viability of lung tissue was determined with WST assay and by life/dead staining using calcein AM/EthD-1 for confocal microscopy (CLSM) followed by quantitative analysis with IMARIS. Inflammation was assessed by measuring chemokine KC and TNF-alpha levels. The in vivo effects were determined in a 16-day repeated-dose inhalation toxicity study using female BALB/c mice, which were daily exposed to different concentrations of SLN30 aerosols (1-200 microg deposit dose). Local inflammatory effects in the respiratory tract were evaluated by determination of total protein content, LDH, chemokine KC, IL-6, and differential cell counts, performed on days 4, 8, 12, and 16 in bronchoalveolar lavage fluid. Additionally, a histopathological evaluation of toxicologically relevant organs was accomplished. The in vitro and ex vivo dose finding experiments showed toxic effects beginning at concentrations of about 500 microg/ml. Therefore, we used 1-200 microg deposit doses/animal for the in vivo experiments. Even after 16 days of challenge with a 200-microg deposit dose, SLNs induced no significant signs of inflammation. We observed no consistent increase in LDH release, protein levels, or other signs of inflammation such as chemokine KC, IL-6, or neutrophilia. In contrast, the particle control (carbon black) caused inflammatory and cytotoxic effects at corresponding concentrations. These results confirm that repeated inhalation exposure to SLN30 at concentrations lower than a 200-microg deposit dose is safe in a murine inhalation model.

Evaluating wastewater-induced plant genotoxicity using randomly amplified polymorphic DNA

Wastewater often contains genotoxic substances that can resist different stages of the treatment process. In the present study, randomly amplified polymorphic DNA technology was applied to evaluate the genotoxic effects of wastewater (treated and raw) irrigation on oat plants (Avena sativa). RAPD profiles obtained showed that both treated and raw wastewater (RWW) were having genotoxic effects on oat plants. This was apparent by the appearance/disappearance of bands in the treatments compared with the control plants. From the 15 primers used, 186 bands were obtained with an average of 12.4 bands per primer. Irrigating plants with RWW caused 51 new bands to appear and 19 to disappear. Treated wastewater (TWW) caused only 16 new bands and the loss of 17 bands. This makes TWW less genotoxic than RWW. The Euclidean distances shown on the dendrogram, revealed the presence of two clusters according to dissimilarity values. One cluster contained the control plants and those irrigated with TWW, whereas the second contained the plants irrigated with RWW. Similarity indices calculated between the treatments and the control plants showed that the control and the plants irrigated with TWW had a similarity index of 0.87, the control and plants irrigated with RWW 0.73 and between the treatments 0.75.

Complex regional pain syndrome with special emphasis on the knee

Complex regional pain syndrome is characterised by an exaggerated response to injury in a limb with intense prolonged pain, vasomotor disturbance, delayed functional recovery and trophic changes. This review describes the current knowledge of the condition and outlines the methods of treatment available with particular emphasis on the knee.

Soft tissue sarcomas: are current referral guidelines sufficient?

INTRODUCTION

To investigate the adequacy of current early referral guidelines for patients with extremity soft tissue sarcomas.

PATIENTS & METHODS

365 patients with confirmed soft tissue sarcomas were evaluated. Data were collected prospectively and included the length of history and the presence of features in current guidelines suggestive of malignancy (pain, rapidity of growth, depth and tumour size). Statistical analysis included the t-test, ANOVA and the Chi test.

RESULTS

Deep tumours were the commonest (306 patients with deep tumours). Pain was the least consistent feature (176 patients with pain). 345 patients with one or more of the guideline features had an average history of 19.86 months, 238 of these were seen after more than 3 months.

CONCLUSION

Although the majority of soft tissue sarcomas in our patients had one or more of the clinical guideline features, there was still an unacceptable delay in referring these patients to a specialist unit. The referral guidelines should be modified with special emphasis on depth, which is the most sensitive, followed by size and a history of rapid growth. This combined with increased awareness of these guidelines and a well-advertised, open-access clinic linked to a specialist unit should allow for a more rapid evaluation of soft tissue tumours.