Information technology for clinical, translational and comparative effectiveness research. Findings from the section clinical research informatics

OBJECTIVES

To summarize advances of excellent current research in the new emerging field of Clinical Research Informatics.

METHOD

Synopsis of four key articles selected for the IMIA Yearbook 2013. The selection was performed by querying PubMed and Web of Science with predefined keywords. From the original set of 590 papers, a first subset of 461 articles which was in the scope of Clinical Research Informatics was refined into a second subset of 79 relevant articles from which 15 articles were retained for peer-review.

RESULTS

The four selected articles exemplify current research efforts conducted in the areas of data representation and management in clinical trials, secondary use of EHR data for clinical research, information technology platforms for translational and comparative effectiveness research and implementation of privacy control.

CONCLUSIONS

The selected articles not only illustrate how innovative information technology supports classically organized randomized controlled trials but also demonstrate that the long promised benefits of electronic health care data for research are becoming a reality through concrete platforms and projects.

Abstract P5-17-04: Management of Antiangiogenics' Renovascular Safety in breast cancer. Subgroup and intermediate results of the MARS Study

Background: Hypertension (HTN) and proteinuria (Pu) are class-side-effects of anti-VEGF drugs (AVD), related to the inhibition of the VEGF pathway. The MARS study has been conducted to assess the renovascular tolerance of these drugs in the clinical setting.

Methods: The MARS study is a multicentric prospective observational study of the renovascular safety of AVD in AVD-naive patients. in 7 centres from 2009 to 2011. There was no intervention on the choice of the AVD. Data collected included: gender, age, serum creatinine (SCr), diabetes, HTN, hematuria (Hu) and dipstick Pu. This sub-group analysis presents the intermediate results for the first 184 patients with breast cancer (BC) receiving bevacizumab who completed the 1-year follow-up (f/u) (out of 337 BC patients in total).

Results: All these 184 patients received bevacizumab (mean and median durations of treatment: 7.8 and 8 months, respectively). Median age at inclusion was 60 years. Bone, visceral and cerebral metastasis frequencies were 75.0, 52.2 and 7.1%, respectively. Diabetes and HTN prevalences were 4.3% and 10.3%, respectively. Baseline renal assessment retrieved: Pu 13.0%, Hu 8.2%, mean aMDRD 98.8 ml/min/1.73m2 and 1.1% had aMDRD<60. The incidence of de novo Pu during f/u was 16.3% (Table). 58.3% of patients with Pu at inclusion improved. Among patients with de novo Pu, 42.3% afterwards improved/normalized. No grade 3/4 Pu has been reported and no hematuria. 12.7% developed HTN. In addition, renal function decreased by −3.4 ml/min/1.73m2/year and 4 patients had aMDRD<60 at the end of f/u. 33.2% increased their SCr: 27.7% grade 1, 4.9% grade 2, and 0.5% grade 3. All patients with grade 2–3 returned to normal or grade 1 during f/u. No thrombotic micro-angiopathy has been reported.

Conclusion: These results show that 1) No thrombotic micro-angiopathy remains rare, 2) Pu developed in 16.3% of patients, with no grade 3/4, 3) less than 13% developed HTN, and 4) renal function was only slightly impaired with transient elevations in SCr. Furthermore, in case of a renovascular effect, investigators followed the recommendations from the French Society of Nephrology (Halimi JM et Al. Nephrol Ther 2008) and no treatment withdrawal for unmanageable renovascular toxicity occurred.

Are warbles and bots related to reproductive status in West Greenland caribou?

In March-April 2008-09, using CARMA protocols, 81 cows and 16 calves were collected in West Greenland from two caribou populations; Akia-Maniitsoq (AM) and Kangerlussuaq-Sisimiut (KS). In both populations, warble larvae numbers were highest in calves and higher in non-pregnant than pregnant cows. Nose bots showed no relationship with pregnancy or lactation; KS calves had higher nose bot loads than cows, a pattern not observed in AM. Pregnant cows had more rump fat than non-pregnant cows. KS cows lacking rump fat entirely had the highest warble burdens. We observed lactating pregnant cows with moderate larval burdens. Projected energy cost of the heaviest observed combined larvae burdens was equivalent to 2-5 days basal metabolic rate (BMR) for a cow, and 7-12 days BMR for a calf. Foregone fattening in adult cows with average burdens was 0.2 to 0.5 kg, but almost doubled with the heaviest infestations to 0.4 and 0.8 kg. Average burdens in calves resulted in forgone fattening of about 0.5 kg, with peak costs equivalent to 0.7 and 1.1 kg fat for AM and KS calves respectively. Although modest, these projected energy costs of hosting larvae for cows support the negative relationship between rump fat and larvae burden. For calves, hosting high burdens of warble larvae could affect winter survival, specifically those weaned normally in October or in early winter. Harmful effects of oestrid larvae burdens may remain subtle but clearly cumulative in relation to seasonal forage availability and incidence of other parasites.

[Pneumocystis jirovecii pneumonia in non-HIV infected patients: a study of 41 cases]

BACKGROUND

The increasing use of immunosuppressive and cytotoxic therapies leads to a growing number of opportunistic infections especially Pneumocystis jirovecii pneumonia (PCP). The purpose of our study was to describe the population involved, and to assess clinical, biological, and mortality data.

METHODS

We collected retrospectively the whole medical file of all PCP cases diagnosed in non-HIV infected patients, in two French University Hospitals in the last decade (1999-2009). Diagnosis was made on standard coloration and/or immunofluorescence analysis of bronchoalveolar lavage fluid (BAL).

RESULTS

Forty-one patients were included in the study, mean age 56 (±12.5) years, sex ratio 0.71 men/woman. Underlying diseases were as follow: 12 patients (29%) were renal transplant recipients, 13 (32%) were treated for solid cancers, and 16 (39%) suffered from various diseases (three allogenic bone-marrow transplantation, 11 hematological malignancies, one pulmonary transplantation, one vasculitis). Twelve patients died (i.e. 29%). Median lymphocyte count was 542/mm(3). More than 85% patients received corticosteroids at a median cumulative 6-month dose of 2700mg. Seven patients (17%) had a PCP prophylaxis. Clinical worsening at day 5 (P<0.003), poor control of the underlying disease (P<0.015), WHO performans status superior than 2 (P<0.025), high temperature (P<0.04), and high oxygen flow (P<0.042) were linked to a poor prognosis.

DISCUSSION/CONCLUSION

The prognosis factors found are mostly linked to the patients' clinical severity. We would like to highlight: first, near to 30% mortality rate, secondly, a lack of prophylaxis in 34 patients, reflecting the difficulty to define PCP's risk in non HIV-infected patients.

Neonatal colonization of mice with Lactobacillus plantarum producing the aeroallergen Bet v 1 biases towards Th1 and T-regulatory responses upon systemic sensitization

BACKGROUND

The use of recombinant lactic acid bacteria (LAB) as vehicles for mucosal delivery of recombinant allergens is an attractive concept for antigen-defined allergy prevention/treatment. Interventions with LAB are of increasing interest early in life when immune programming is initiated. Here, we investigated the effect of neonatal colonization with a recombinant LAB producing the major birch pollen allergen Bet v 1 in a murine model of type I allergy.

METHODS

We constructed a recombinant Lactobacillus (L.) plantarum NCIMB8826 strain constitutively producing Bet v 1 to be used for natural mother-to-offspring mono-colonization of germ-free BALB/c mice. Allergen-specific immunomodulatory effects of the colonization on humoral and cellular immune responses were investigated prior and after sensitization to Bet v 1.

RESULTS

Mono-colonization with the Bet v 1 producing L. plantarum induced a Th1-biased immune response at the cellular level, evident in IFN-γ production of splenocytes upon stimulation with Bet v 1. After sensitization with Bet v 1 these mice displayed suppressed IL-4 and IL-5 production in spleen and mesenteric lymph node cell cultures as well as decreased allergen-specific antibody responses (IgG1, IgG2a, and IgE) in sera. This suppression was associated with a significant up-regulation of the regulatory marker Foxp3 at the mRNA level in the spleen cells.

CONCLUSION

Intervention at birth with a live recombinant L. plantarum producing a clinically relevant allergen reduces experimental allergy and might therefore become an effective strategy for early intervention against the onset of allergic diseases.

Spin–orbit ab initio investigation of the UV photoinduced bond cleavage in iodotrimethylstannane

The photoinduced homolytic cleavage of the Sn–I bond in iodotrimethylstannane (CH3)3SnI, observed after UV irradiation, is investigated by means of spin–orbit ab initio calculations based on CASSCF (complete active space self-consistent field) and MS-CASPT2 (multi-state complete active space 2nd order perturbation theory) methods. The absorption electronic spectrum is characterized by ten low-lying 1,3A′ and 1,3A″ spin eigenstates corresponding to py(I),px(I) → σ*SnI; σSnI → σ*SnI and py(Sn), px(Sn) → σ*SnI, where σSnI and σ*SnI are the bonding and anti-bonding orbitals of the Sn–I bond along the pz axis. From the 1A′ electronic ground state and these ten spin eigenstates, 21 spin–orbit states are generated leading to various deactivation channels of (CH3)3SnI, corresponding to the formation of radicals (CH3)3Sn• and •I and to the ionic species (CH3)3Sn+ and I–. Irradiation into the upper band at 175 nm should lead to the heterolytic cleavage of the Sn–I bond to form the ionic primary products exclusively, whereas absorption into the shoulder at 250 nm induces the homolytic breaking with formation of the radical products.

[Anatomic pathology workflow. IHE: modeling based on current developments in HL7 and DICOM]

AIMS

Consistent and complete information is essential for medical decision making. Anatomic pathology as a diagnostic discipline has a central role in the exchange of information between clinical departments throughout the diagnostic process. The IHE (Integrating the Healthcare Enterprise) has created an integration profile for information systems based on HL7 and DICOM standards.

METHODS

Created by the IHE Anatomic Pathology working group, the integration profile (so-called Technical Framework) ensures the consistent management of data and material in the pathology laboratory information system (PLIS). HL7 and DICOM standards are taken into account. Communication processes both within and outside the institute are modelled using eight actors and 13 transactions.

RESULTS

The IHE's Technical Framework covers basic business processes, provision of diagnostic services and includes requesting examinations, as well as image and report management. In particular, a consistent data model for incoming material, containers, cartridges and slides has been developed and approved by the standards committee.

Immunomodulatory properties of Lactobacillus plantarum and its use as a recombinant vaccine against mite allergy

BACKGROUND

Selected lactic acid bacteria were reported to prevent atopic dermatitis and experimental asthma but the mechanisms of their immunomodulatory effects are not fully elucidated. In this study, the signaling pathways triggered by Lactobacillus plantarum NCIMB8826 were investigated and the potential use of this strain producing a variant of the mite allergen Der p 1 as live vaccine vehicle was evaluated.

METHODS

Mouse bone marrow-derived dendritic cells were stimulated with wild-type or a L. plantarum teichoic acid mutant to evaluate the secretion of cytokines. A recombinant L. plantarum expressing Der p 1 was engineered, its in vitro immunomodulatory properties were characterized and its prophylactic potential was evaluated in a Der p 1-sensitization murine model.

RESULTS

Mouse dendritic cells stimulated by L. plantarum triggered the release of interleukin-10 (IL-10), IL-12 p40, IL-12 p70 and tumor necrosis factor-alpha (TNF-alpha). IL-12 p40 secretion was dependent on nuclear factor-kappaB (NF-kappaB), mitogen-activated protein (MAP) kinases, Toll-like receptor 2 (TLR2), TLR9 and on the bacterial teichoic acid composition. Recombinant L. plantarum producing Der p 1 exhibited similar immunostimulatory properties as wild-type. Prophylactic intranasal pretreatment of mice with this recombinant strain prevented the development of the typical Th2-biased allergic response by a drastic reduction of specific IgE and the induction of protective allergen-specific IgG2a antibodies. Moreover, both wild-type or recombinant L. plantarum reduced airway eosinophilia following aerosolized allergen exposure and IL-5 secretion upon allergen restimulation.

CONCLUSION

By combining both Th1-type immunostimulatory properties and an efficient allergen delivery capacity, recombinant L. plantarum producing Der p 1 represents a promising vaccine against house dust mite allergy.

[Using a pleural implantable access system for the management of malignant pleural effusions. Experience of Institut Curie]

PURPOSE

Malignant pleural effusion has a very poor prognosis, raises problems of medical management and impairs quality of life. The authors report the first experience of a pleural implantable access system for the treatment of recurrent symptomatic malignant pleural effusion.

DESCRIPTION

Prospective follow-up of 26 patients between 20/8/2005 and 2/11/2006 in a single center. Thirty pleural implantable access systems were placed in 26 patients (22 patients with breast cancers, 3 bilateral placements and one case of replacement) under sedation following the decision of a multidisciplinary meeting.

EVALUATION

Twenty-five patients obtained partial or complete relief of their dyspnea. Four patients underwent spontaneous pleurodesis after a maximum of 2 months. Twelve patients were receiving chemotherapy at the time of placement. The number of aspirations performed varied between 1 and 28 over a period of 11 to 330 days. Eight patients died within 1 month after placement of the system and 6 survived more than 6 months. Seven patients died at Institut Curie or in a palliative care unit without returning home. The other 16 patients presented a total of 198 days of hospitalization for 2,305 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pleuro-pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient developed loculation of the pleural cavity after 16 thoracenteses making further thoracentesis ineffective.

CONCLUSIONS

The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It shows a number of advantages in terms of comfort and infectious risk compared to tunneled pleural catheters.

The European LABDEL project and its relevance to the prevention and treatment of allergies

In March 2001, the European Commission funded a 3-year project (contract no. QLK3-CT-2000-00340) under the fifth Framework Programme to develop and test prototype products based on the oral delivery of vaccine and therapeutic agents using harmless lactic acid bacteria (LAB). The project, best known under its acronym LABDEL (for LAB delivery) also included research on LAB fermentation and technological innovations aimed at enhancing the efficiency of LAB delivery systems (1). One of the key scientific objectives was to investigate the possibility to prevent or treat a type I allergic disease using mucosal administration of LAB expressing the pollen allergen Bet v 1. The aim of this paper was to describe the background of the project with reference to a limited selection of articles and recent reviews as well as the results and major conclusions arising from this part of the project.

Electronic Healthcare Record and clinical research in cardiovascular radiology. HL7 CDA and CDISC ODM interoperability

Integrating clinical research data entry with patient care data entry is a challenging issue. At the G. Pompidou European Hospital (HEGP), cardiovascular radiology reports are captured twice, first in the Electronic Health Record (EHR) and then in a national clinical research server. Informatics standards are different for EHR (HL7 CDA) and clinical research (CDISC ODM). The objective of this work is to feed both the EHR and a Clinical Research Data Management System (CDMS) from a single multipurpose form. We adopted and compared two approaches. First approach consists in implementing the single "care-research" form within the EHR and aligning XML structures of HL7 CDA document and CDISC ODM message to export relevant data from EHR to CDMS. Second approach consists in displaying a single "care-research" XForms form within the EHR and generating both HL7 CDA document and CDISC message to feed both EHR and CDMS. The solution based on XForms avoids overloading both EHR and CDMS with irrelevant information. Beyond syntactic interoperability, a perspective is to address the issue of semantic interoperability between both domains.