Implementation of an Emergency Medical Card and a Continuity of Care

Objectives: To describe the design and implementation procedures for an emergency medical card (EMC) and a continuity of care (CoC) report using the continuity of care record (CCR) standard. We also describe studies to evaluate the effectiveness of these documents in Co C.

Methods: We convened weekly planning, design, development, implementation, and evaluation meetings, involving 25 outpatient clinics at Intermountain Healthcare. The CCR standard schema and documentation from American Society for Testing and Materials were used to develop the data model. An outside consultant provided further advice on committee-approved designs. We then developed a functional design document for the CCR application implementation. Healthcare professionals (medical doctors and physician assistants) and fourth-year medical students will simulate the will simulate the EMC and CoC report use and assess their usefulness in Co C. The reviewers will review three randomly selected patient cases, using patient information in the electronic medical record, EMC and CoC report. A structured questionnaire with Likert scale will assess the reviewers’ perceptions of the documents’ usefulness in medical decision making. Other studies will compare patient- and HCP-entered data to evaluate the effect of patient-entered data on the quality of HCP-entered data and assess user-satisfaction with the documents’ usefulness in Co C.

Results: An automated CCR application compliant with the CCR standard was developed and integrated in an already implemented patient portal at the Intermountain Healthcare clinics. Patients use the application to view, add, modify their information and use the data plus EMR data to create EMC and CoC report.

Conclusions: The CCR standard can be used to implement an application to enable patients to not only view but add or modify personal health records, and create, print and share paper EMC and CoC report with HCPs. The documents can be created using HCP-maintained EMR data, in addition to patient-entered data as is currently the norm.

Abstract P6-08-01: Perceptions of breast cancer risk, psychological adjustment and behaviors in adolescent girls at high-risk and population-risk for breast cancer

BACKGROUND: Preliminary evidence suggests that many girls from breast cancer (BC) families are aware of their increased risk for BC. How this awareness impacts their psychosocial adjustment and health behaviors remains unknown.

METHODS: 11–19 YO girls at high-risk (HR) or population-risk (PR) for BC completed self-administered quantitative surveys informed by the Self-Regulation Theory of Health Behavior. Girls with a first or second-degree relative with BC were classified as HR. For hypothesis testing, we used simple linear and logistic regressions. To account for correlation of responses within families, we used robust (cluster-corrected) standard errors or Generalized Estimating Equations.

RESULTS: 47 PR and 89 HR girls have completed surveys. Age did not differ between groups (Mage = 15.6; SD=2.4). 30% of HR girls have a mother with BC. 67% of HR girls vs. 30% of PR girls reported self-perceived risk for adult BC to be “higher than other girls my age,” (p = <0.01, Table 1).

Patient-perceived usefulness of an emergency medical card and a continuity-of-care report in enhancing the quality of care

OBJECTIVE

To evaluate the patients' opinion on the usefulness of the electronic medical card (EMC) and continuity-of-care report in enhancing quality of care, and to assess the effects of the patient-entered data on the quality of data in the electronic medical record (EMR).

DESIGN

A structured survey assessed patients' opinion on the usefulness of the EMC and continuity-of-care report. The accuracy of EMR data involved comparing the patient-entered data in the continuity-of-care report with the healthcare-provider-entered data in the EMR. The analysis assessed whether the EMR information was consistent with the patient-entered data. A data completeness evaluation compared data entries in the EMR collected before and after the use of continuity-of-care record application.

RESULTS

One hundred and thirty-three patients used the application, of which 76% who had actually used the EMC and continuity-of-care report to seek medical care and/or update EMR information were surveyed. Age was associated with the reported usefulness of the documents. Few users (16%) printed the continuity-of-care reports to take to their healthcare providers for data updates and fewer (9%) to correct errors in the EMR. Overall, 68% of patients found the documents to be useful.

CONCLUSIONS

Patients reported that the EMC and continuity-of-care report were useful in enhancing quality of care. They were able to identify missing or erroneous data in the EMR data, making them an important source of quality control for their information in the healthcare-provider-maintained EMR.

KX-01, a Novel Src Kinase Inhibitor Directed towards the Peptide Substrate Site, Induces Robust Apoptosis and Synergizes with Tamoxifen and Chemotherapy in Breast Cancer

New therapeutic regimens that increase efficacy or reduce onset of resistance for endocrine therapy and chemotherapy are needed for better clinical management of breast cancer. c-Src is an oncogenic non-receptor tyrosine kinase that is up-regulated in approximately half of all breast cancer. However the efficacy of existing multi-kinase src inhibitors in breast cancer has been limited. KX-01 (Kinex Pharmaceuticals) is a novel class of non-ATP src inhibitor that targets the peptide binding site of src and is currently completing Phase-1 testing for solid tumors. In a panel of breast cancer cell lines, KX-01 resulted in dose dependent inhibition of growth and induction of apoptosis that was independent of p53 status, and was preceded by rapid inhibition of src activity. KX-01 induced apoptosis in two cell lines reported to be resistant to multi-kinase src inhibitors, MDA-MB-468 cells and BT-549. Cell cycle analysis revealed that KX-01 (50 nM, 6 hours) resulted in significant accumulation of MDA-MB-231 cells (ERα/PR/HER2/neu negative) and MCF-7 cells (ERα positive) in G2/M phase. Immunofluorescent staining for mitotic phase marker phospho-histone 3 indicated that cells had arrested in mitotic phase and many of the mitotic arrested cells were undergoing apoptosis (TUNEL), a novel cell death for a small molecule tyrosine kinase inhibitor. KX-01 induced nuclear accumulation of cyclin B1, and activation of CDK1, MPM2 and Cdc25C that is required for progression past the G2/M checkpoint. KX-01 resulted in cytochrome C release and activation of caspases 3, 6, 7, 8 and 9. A matrix design using the median-effect principle to delineate the interaction between two drugs was applied for KX-01 alone and in combination tamoxifen (TAM), paclitaxel (PAC) or doxorubicin (DOX). Combinations of KX-01 (5-75 nM) with each of these agents resulted in synergistic growth inhibition of MCF-7 cells (KX-01 + TAM) and MDA-MB-231 cells (KX-01 + DOX or PAC). In addition, synergistic induction of apoptosis was achieved by combining low doses of KX-01 with DOX, PAC or TAM. c-Src induces phosphorylation of ERα at serines 118 and 167, sites required for full receptor activity. KX-01 combined with TAM resulted in decreased phosphorylation at serine 167 that was associated with reduced transcriptional activity of ERα. In tumor xenograft models, KX-01 resulted in a dose dependent inhibition of MDA-MB-231 and MCF-7 tumor growth after 30 days (1, 2.5 or 5 mg/kg body weight, twice daily by oral gavage). In MDA-MB-231 xenografts, KX-01 reduced metastasis to bone (femur) and lung as measured by PCR for detection of human chromosome 17.These data define KX-01 as a potently active src kinase inhibitor that induces robust cell death, tumor growth inhibition and anti-metastatic effects. Combinations of KX-01 with endocrine therapy and chemotherapy present a promising new strategy for clinical management of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6104.

Isolation of Tumor Initiating Cells with Metastatic Potential from Human Primary Invasive Ductal Carcinoma

Disseminated breast cancer cells may be present at distant sites at the time of primary diagnosis of breast cancer in patients that exhibit no outward signs of clinical metastasis. It is hypothesized that early breast cancer metastasis is initiated by a small population of breast tumor initiating cells (bTICs) within the primary tumor that are inherently resistant to chemotherapy and hormonal therapy. To better understand the biological pathways that permit bTICs to metastasize and to evade current breast cancer therapies, bTICs have been isolated from breast cancer biopsies from patients diagnosed with primary invasive ductal carcinoma. Breast cancer needle biopsies from primary tumors were obtained during the routine care of patients with consent and IRB approval. Core biopsies were mechanically and enzymatically dissociated, yielding a single cell suspension which was subsequently cultured under non-adherent and serum-free conditions to obtain tumorspheres. Injection of about 500 bTICs into the mammary fat pad of female nude mice resulted in tumor formation at the site of injection within two months that was maintained as a small palpable mass for at least six months. H+E staining of sections of the primary tumors revealed complex cellular organization and both microvascular and macrovascular structures. Serial transplantation of the primary tumors from the 6/7 samples resulted in tumor formation at the site of injection. Upon primary tumor formation in the mammary fat pad, metastatic human breast cancer cells were detected within the lungs, liver, brain and bone marrow (femur) from 5/7 tumors after six months. Metastatic cells were detected by PCR for an alpha-satellite sequence in the centromeric region in human Chromosome 17, and by in situ hybridization using an human specific Alu DNA oligonucleotide probe. Metastatic bTICs were mostly detected as single cells or small clustering of cells present throughout the metastatic organ. These data demonstrate that cells with the phenotype of “tumor initiating cells” can be isolated from primary biopsies of human invasive ductal carcinoma and cultured in vitro. Unlike direct heterotransplant tissues from primary tumor biopsies, the majority of bTICs samples form tumors when injected into immunodeficient mice and further exhibit a highly metastatic phenotype.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 504.

Alternative splicing, muscle calcium sensitivity, and the modulation of dragonfly flight performance

Calcium sensitivity of myosin cross-bridge activation in striated muscles commonly varies during ontogeny and in response to alterations in muscle usage, but the consequences for whole-organism physiology are not well known. Here we show that the relative abundances of alternatively spliced transcripts of the calcium regulatory protein troponin T (TnT) vary widely in flight muscle of Libellula pulchella dragonflies, and that the mixture of TnT splice variants explains significant portions of the variation in muscle calcium sensitivity, wing-beat frequency, and an index of aerodynamic power output during free flight. Two size-distinguishable morphs differ in their maturational pattern of TnT splicing, yet they show the same relationship between TnT transcript mixture and calcium sensitivity and between calcium sensitivity and aerodynamic power output. This consistency of effect in different developmental and physiological contexts strengthens the hypothesis that TnT isoform variation modulates muscle calcium sensitivity and whole-organism locomotor performance. Modulating muscle power output appears to provide the ecologically important ability to operate at different points along a tradeoff between performance and energetic cost.

Eye injury and sport: sport-related eye injuries presenting to an eye casualty department throughout 1995

A survey was undertaken of all patients attending the Eye Casualty Department at Waterford Regional Hospital with sports injuries in the twelve-month period 1st January 1995 to 31st December 1995. Ninety eight patients had problems associated with sport. Hurling was responsible for the largest group (30%) and football of different codes accounted for 29%. The next largest group was the racquet sports (13%). The most common injuries were to the anterior chamber (hyphaema and microhyphaema: 36%). There were three orbital fractures. 26 patients (27%) were admitted. 83 patients (85%) were male. The median age was 20 years. Sport is a significant cause of eye injury, which is often serious, and affects mostly young healthy males.

Serum type III procollagen aminopeptide for assessing liver damage in methotrexate-treated psoriatic patients

This study was designed to establish whether measurement of a serological marker of fibrosis might reduce the need for liver biopsy in psoriatic patients receiving methotrexate (MTX). Levels of type III procollagen aminopeptide (PIIINP-O and PIIINP-B) and laminin P1 (LamP1-B) were measured in 147 serum samples taken at the time of liver biopsy in 87 patients receiving long-term MTX treatment for severe psoriasis. Biopsies were classified as: (1) normal, (2) steatosis, (3) inflammation, (4) fibrosis, or (5) cirrhosis. Groups 3-5 were considered to show clinically relevant abnormality. Compared with controls, PIIINP-O was significantly raised in the group of MTX-treated psoriatics (P < 0.001). Within this group, levels were significantly higher in patients with inflammation, fibrosis or cirrhosis compared with those with normal histology or steatosis alone (P < 0.0001). In contrast, PIIINP-B and LamP1-B did not distinguish between controls and MTX-treated patients or between histological groups. Forty-two patients had two or more biopsies with simultaneous PIIINP-O measurement. PIIINP-O levels at the time of the first biopsy were normal in six of the seven patients whose histology was initially normal and subsequently became abnormal. A single measurement of PIIINP-O thus did not predict which patients might develop abnormal histology following further MTX. In a group of 17 patients, PIIINP-O was measured 3-monthly for up to 6 years during MTX treatment. PIIINP-O was elevated at some time during follow-up in all three patients who developed abnormal histology but was consistently normal in eight of the 11 patients whose histology remained or became normal. Our findings indicate that PIIINP-O is of value in detecting liver damage and, particularly if measured serially, may reduce the need for liver biopsy in MTX-treated patients. Although the test does not detect all patients with fibrosis, it would appear that the risk of missing significant liver damage in patients with persistently normal PIIINP-O is low.

Abnormalities of serum type III procollagen aminoterminal peptide in methotrexate-treated psoriatic patients with normal liver histology do not correlate with hepatic ultrastructural changes

In a previous study, it was shown that the serum levels of type III procollagen aminoterminal peptide (P3NP) were significantly greater in patients receiving methotrexate (MTX) treatment for psoriasis than in untreated control patients with psoriasis. Although levels were highest in patients with hepatic fibrosis and cirrhosis, serum P3NP concentrations in those patients with normal liver histology on light microscopy were also shown to be significantly higher than in controls. In the present study, liver biopsies from 22 such 'normal' patients were examined by electron microscopy, in order to determine whether P3NP levels correlated with ultrastructurally demonstrable fibrosis. Fibrosis in the perisinusoidal space of Disse was present in as many as 82% of biopsies. Although the prevalence of such fibrosis in psoriasis patients who have not received MTX is unknown, the high prevalence of Disse space fibrosis and of raised P3NP in MTX-treated patients suggests that MTX causes subtle liver damage in a majority of treated patients. However, we were unable to show a statistical correlation between P3NP and the degree of Disse space fibrosis.

Serum type III procollagen peptide, dynamic liver function tests and hepatic fibrosis in psoriatic patients receiving methotrexate

The serum level of the aminoterminal peptide of type III procollagen (P3NP) was measured in 51 psoriatic patients on long-term, once weekly, low-dose methotrexate and in a control group of patients with extensive psoriasis who had never had systemic treatment. Serum P3NP levels were normal in all control patients, but were elevated in the majority of methotrexate-treated patients, even those with normal or non-specific liver histology. Although the highest P3NP values were found in the groups of patients with fibrosis and cirrhosis, isolated P3NP measurements did not discriminate between individuals with and without significant liver pathology. Neither standard nor dynamic liver function tests were able to identify patients with significant liver damage and in most cases results were in the normal range.