HerediGene Population Study IT infrastructure: A model to support genomic research recruitment and precision public health

The HerediGene Population Study is a large research study focused on identifying new genetic biomarkers for disease prevention, diagnosis, prognosis, and development of new therapeutics. A substantial IT infrastructure evolved to reach enrollment targets and return results to participants. More than 170,000 participants have been enrolled in the study to date, with 5.87% of those whole genome sequenced and 0.46% of those genotyped harboring pathogenic variants. Among other purposes, this infrastructure supports: (1) identifying candidates from clinical criteria, (2) monitoring for qualifying clinical events (e.g., blood draw), (3) contacting candidates, (4) obtaining consent electronically, (5) initiating lab orders, (6) integrating consent and lab orders into clinical workflow, (7) de-identifying samples and clinical data, (8) shipping/transmitting samples and clinical data, (9) genotyping/sequencing samples, (10) and re-identifying and returning results for participants where applicable. This study may serve as a model for similar genomic research and precision public health initiatives.

Engineering Electrode Rinse Solution Fluidics for Carbon-Based Reverse Electrodialysis Devices

Natural salinity gradients are a promising source of so-called "blue energy", a renewable energy source that utilizes the free energy of mixing for power generation. One promising blue energy technology that converts these salinity gradients directly into electricity is reverse electrodialysis (RED). Used at its full potential, it could provide a substantial portion of the world's electricity consumption. Previous theoretical and experimental works have been done on optimizing RED devices, with the latter often focusing on precious and expensive metal electrodes. However, in order to rationally design and apply RED devices, we need to investigate all related transport phenomena─especially the fluidics of salinity gradient mixing and the redox electrolyte at various concentrations, which can have complex intertwined effects─in a fully functioning and scalable system. Here, guided by fundamental electrochemical and fluid dynamics theories, we work with an iron-based redox electrolyte with carbon electrodes in a RED device with tunable microfluidic environments and study the fundamental effects of electrolyte concentration and flow rate on the potential-driven redox activity and power output. We focus on optimizing the net power output, which is the difference between the gross power output generated by the RED device and the pumping power input, needed for salinity gradient mixing and redox electrolyte reactions. We find through this holistic approach that the electrolyte concentration in the electrode rinse solution is crucial for increasing the electrical current, while the pumping power input depends nonlinearly on the membrane separation distance. Finally, from this understanding, we designed a five cell-pair (CP) RED device that achieved a net power density of 224 mW m-2 CP-1, a 60% improvement compared to the nonoptimized case. This study highlights the importance of the electrode rinse solution fluidics and composition when rationally designing RED devices based on scalable carbon-based electrodes.

The Development of an Infrastructure to Facilitate the Use of Whole Genome Sequencing for Population Health

The clinical use of genomic analysis has expanded rapidly resulting in an increased availability and utility of genomic information in clinical care. We have developed an infrastructure utilizing informatics tools and clinical processes to facilitate the use of whole genome sequencing data for population health management across the healthcare system. Our resulting framework scaled well to multiple clinical domains in both pediatric and adult care, although there were domain specific challenges that arose. Our infrastructure was complementary to existing clinical processes and well-received by care providers and patients. Informatics solutions were critical to the successful deployment and scaling of this program. Implementation of genomics at the scale of population health utilizes complicated technologies and processes that for many health systems are not supported by current information systems or in existing clinical workflows. To scale such a system requires a substantial clinical framework backed by informatics tools to facilitate the flow and management of data. Our work represents an early model that has been successful in scaling to 29 different genes with associated genetic conditions in four clinical domains. Work is ongoing to optimize informatics tools; and to identify best practices for translation to smaller healthcare systems.

Microscale hydrodynamic confinements: shaping liquids across length scales as a toolbox in life sciences

Hydrodynamic phenomena can be leveraged to confine a range of biological and chemical species without needing physical walls. In this review, we list methods for the generation and manipulation of microfluidic hydrodynamic confinements in free-flowing liquids and near surfaces, and elucidate the associated underlying theory and discuss their utility in the emerging area of open space microfluidics applied to life-sciences. Microscale hydrodynamic confinements are already starting to transform approaches in fundamental and applied life-sciences research from precise separation and sorting of individual cells, allowing localized bio-printing to multiplexing for clinical diagnosis. Through the choice of specific flow regimes and geometrical boundary conditions, hydrodynamic confinements can confine species across different length scales from small molecules to large cells, and thus be applied to a wide range of functionalities. We here provide practical examples and implementations for the formation of these confinements in different boundary conditions - within closed channels, in between parallel plates and in an open liquid volume. Further, to enable non-microfluidics researchers to apply hydrodynamic flow confinements in their work, we provide simplified instructions pertaining to their design and modelling, as well as to the formation of hydrodynamic flow confinements in the form of step-by-step tutorials and analytical toolbox software. This review is written with the idea to lower the barrier towards the use of hydrodynamic flow confinements in life sciences research.

Translating Dental, Oral, and Craniofacial Regenerative Medicine Innovations to the Clinic through Interdisciplinary Commercial Translation Architecture

Few university-based regenerative medicine innovations in the dental, oral, and craniofacial (DOC) space have been commercialized and affected clinical practice in the United States. An analysis of the commercial translation literature and National Institute for Dental and Craniofacial Research's (NIDCR's) portfolio identified barriers to commercial translation of university-based DOC innovations. To overcome these barriers, the NIDCR established the Dental Oral Craniofacial Tissue Regeneration Consortium. We provide generalized strategies to inform readers how to bridge the "valley of death" and more effectively translate DOC technologies from the research laboratory or early stage company environment to clinical trials and bring needed innovations to the clinic. Three valleys of death are covered: 1) from basic science to translational development, 2) from translational technology validation to new company formation (or licensing to an existing company), and 3) from new company formation to scaling toward commercialization. An adapted phase-gate model is presented to inform DOC regenerative medicine teams how to involve regulatory, manufacturability, intellectual property, competitive assessments, business models, and commercially oriented funding mechanisms earlier in the translational development process. An Industrial Partners Program describes how to conduct market assessments, industry maps, business development processes, and industry relationship management methods to sustain commercial translation through the later-stage valley of death. Paramount to successfully implementing these methods is the coordination and collaboration of interdisciplinary teams around specific commercial translation goals and objectives. We also provide several case studies for translational projects with an emphasis on how they addressed DOC biomaterials for tissue regeneration within a rigorous commercial translation development environment. These generalized strategies and methods support innovations within a university-based and early stage company-based translational development process, traversing the many funding gaps in dental, oral, and craniofacial regenerative medicine innovations. Although the focus is on shepherding technologies through the US Food and Drug Administration, the approaches are applicable worldwide.

Reconfigurable microfluidics: real-time shaping of virtual channels through hydrodynamic forces

To break the current paradigm in microfluidics that directly links device design to functionality, we introduce microfluidic "virtual channels" that can be dynamically shaped in real-time. A virtual channel refers to a flow path within a microfluidic flow cell, guiding an injected reagent along a user-defined trajectory solely by hydrodynamic forces. Virtual channels dynamically reproduce key microfluidic functionality: directed transport of minute volumes of liquid, splitting, merging and mixing of flows. Virtual channels can be formed directly on standard biological substrates, which we demonstrate by sequential immunodetection at arrays of individual reaction sites on a glass slide and by alternating between local and global processing of surface-adherent cell-block sections. This approach is simple, versatile and generic enough to form the basis of a new class of microfluidic techniques.

Long-term control of olfactory neuroblastoma in a dog treated with surgery and radiation therapy

BACKGROUND

Olfactory neuroblastoma is a rare malignancy of the nasal cavity in dogs that is thought to arise from specialised sensory neuroendocrine olfactory cells derived from the neural crest.

CASE REPORT

An 8-year-old dog was presented for reclusiveness and pacing. On CT and MRI, a contract-enhancing mass was disclosed within the rostral fossa, extending caudally from the cribriform plate into the left nasal sinus. Surgical excision was performed and the diagnosis was histological grade III (Hyams grading scheme) olfactory neuroblastoma. Based on human CT criteria this was high stage (modified Kadish stage C). Surgical excision was incomplete and was followed by curative-intent radiation therapy using a linear accelerator to a total dose of 48 Gy.

CONCLUSION

The dog survived 20 months after diagnosis. Although olfactory neuroblastoma is a rare tumour in dogs, aggressive local therapy may allow for prolonged survival, even when the tumour is advanced.

Clinical, computed tomographic, magnetic resonance imaging, and histologic findings associated with myxomatous neoplasia of the temporomandibular joint in two dogs

CASE DESCRIPTION A 15-year-old neutered female mixed-breed dog (dog 1) and an 11-year-old neutered female Labrador Retriever (dog 2) were examined because of unilateral exophthalmus, third eyelid protrusion, and periorbital swelling that failed to respond to antimicrobial treatment. CLINICAL FINDINGS Both dogs underwent ultrasonographic, CT, and MRI examination of the head. In both dogs, advanced imaging revealed a poorly defined, peripherally contrast-enhancing, mucous-filled cystic mass that radiated from the temporomandibular joint and infiltrated the periorbital tissues and retrobulbar space. Both dogs underwent surgical biopsy of the periorbital mass. A viscous, straw-colored fluid was aspirated from the retrobulbar region in both dogs. The initial histologic diagnosis for dog 1 was zygomatic sialadenitis and sialocele. However, the clinical signs recurred, and histologic examination of specimens obtained during a second surgical biopsy resulted in a diagnosis of myxoma. The histologic diagnosis was myxosarcoma for dog 2. TREATMENT AND OUTCOME In both dogs, clinical signs recurred within 2 weeks after surgery and persisted for the duration of their lives. Dog 1 received no further treatment after the second surgery and was euthanized 34 months after initial examination because of multicentric lymphoma. Dog 2 was treated with various chemotherapy agents and was euthanized 11 months after initial examination because of a dramatic increase in periocular swelling and respiratory stertor. CLINICAL RELEVANCE Temporomandibular myxomatous neoplasia can be confused with zygomatic sialocele on the basis of clinical signs but has characteristic MRI features. Representative biopsy specimens should be obtained from areas close to the temporomandibular joint to avoid misdiagnosis.

Chemotherapy for dogs with lymph node metastasis from histiocytic sarcomas

BACKGROUND

Histiocytic sarcomas (HS) frequently metastasise, most commonly to visceral sites, but also to regional lymph nodes. Nodal metastases are associated with a poorer prognosis. This retrospective study aimed to evaluate prognostic factors, including the effect of adjuvant chemotherapy, on survival in dogs with nodal, but not systemic, metastases from HS.

METHODS

Retrospective case series of 12 dogs with histologically diagnosed HS metastatic to lymph nodes treated with surgery with and without adjuvant chemotherapy.

RESULTS

All dogs had histological evidence of metastasis to lymph nodes, with no clinical evidence for metastasis to viscera. Eight dogs that received chemotherapy had a median estimated survival of 219 days (range 77-1638 days); 1- and 2-year estimated survival rates were 37.7%. Median survival time for 4 dogs with nodal metastases that did not receive chemotherapy was 57 days (range 39-136 days) with none alive 1 year after surgery CONCLUSION: Survival for dogs with only regional nodal metastases from HS appeared to be improved by adjuvant chemotherapy.

Convection-Enhanced Biopatterning with Recirculation of Hydrodynamically Confined Nanoliter Volumes of Reagents

We present a new methodology for efficient and high-quality patterning of biological reagents for surface-based biological assays. The method relies on hydrodynamically confined nanoliter volumes of reagents to interact with the substrate at the micrometer-length scale. We study the interplay between diffusion, advection, and surface chemistry and present the design of a noncontact scanning microfluidic device to efficiently present reagents on surfaces. By leveraging convective flows, recirculation, and mixing of a processing liquid, this device overcomes limitations of existing biopatterning approaches, such as passive diffusion of analytes, uncontrolled wetting, and drying artifacts. We demonstrate the deposition of analytes, showing a 2- to 5-fold increase in deposition rate together with a 10-fold reduction in analyte consumption while ensuring less than 6% variation in pattern homogeneity on a standard biological substrate. In addition, we demonstrate the recirculation of a processing liquid using a microfluidic probe (MFP) in the context of a surface assay for (i) probing 12 independent areas with a single microliter of processing liquid and (ii) processing a 2 mm² surface to create 170 antibody spots of 50 × 100 μm² area using 1.6 μL of liquid. We observe high pattern quality, conservative usage of reagents, micrometer precision of localization and convection-enhanced fast deposition. Such a device and method may facilitate quantitative biological assays and spur the development of the next generation of protein microarrays.

Computerization of Mental Health Integration complexity scores at Intermountain Healthcare

Intermountain Healthcare's Mental Health Integration (MHI) Care Process Model (CPM) contains formal scoring criteria for assessing a patient's mental health complexity as "mild," "medium," or "high" based on patient data. The complexity score attempts to assist Primary Care Physicians in assessing the mental health needs of their patients and what resources will need to be brought to bear. We describe an effort to computerize the scoring. Informatics and MHI personnel collaboratively and iteratively refined the criteria to make them adequately explicit and reflective of MHI objectives. When tested on retrospective data of 540 patients, the clinician agreed with the computer's conclusion in 52.8% of the cases (285/540). We considered the analysis sufficiently successful to begin piloting the computerized score in prospective clinical care. So far in the pilot, clinicians have agreed with the computer in 70.6% of the cases (24/34).

Spontaneous dormancy of metastatic breast cancer cells in an all human liver microphysiologic system

Background:

Metastatic outgrowth in breast cancer can occur years after a seeming cure. Existing model systems of dormancy are limited as they do not recapitulate human metastatic dormancy without exogenous manipulations and are unable to query early events of micrometastases.

Methods:

Here, we describe a human ex vivo hepatic microphysiologic system. The system is established with fresh human hepatocytes and non-parenchymal cells (NPCs) creating a microenvironment into which breast cancer cells (MCF7 and MDA-MB-231) are added.

Results:

The hepatic tissue maintains function through 15 days as verified by liver-specific protein production and drug metabolism assays. The NPCs form an integral part of the hepatic niche, demonstrated within the system through their participation in differential signalling cascades and cancer cell outcomes. Breast cancer cells intercalate into the hepatic niche without interfering with hepatocyte function. Examination of cancer cells demonstrated that a significant subset enter a quiescent state of dormancy as shown by lack of cell cycling (EdU⁻ or Ki67⁻). The presence of NPCs altered the cancer cell fraction entering quiescence, and lead to differential cytokine profiles in the microenvironment effluent.

Conclusions:

These findings establish the liver microphysiologic system as a relevant model for the study of breast cancer metastases and entry into dormancy.

Abstract P5-04-08: Modeling breast cancer dormancy

Most cancer mortality results from distant metastases. The metastatic microenvironment protects ectopic tumors, these nodules are often resistant to agents that eradicate the primary mass. Although significant interventional progress has been made on primary tumors, the lack of relevant accessible model in vitro systems in which to study metastases has plagued metastatic therapeutic development – particularly among micrometastases. One third of women diagnosed with breast cancer (BC) will have metastatic disease which often presents years after a seeming cure from the primary malignancy. An in silico model of micrometastases strongly suggests that these disseminated cells are quiescent, or ‘dormant’, for long periods of time. Current models fail to recapitulate metastatic dormancy, in vivo due to issues of spontaneous metastases and rodent lifespan and in vitro due to the nascent state of organotypic organs or microphysiological systems (MPS). We hypothesize that even the most developed MPS do not allow tumors to attain dormancy due to continued stress signaling from stiff matrices and an artificial microenvironment. We use an innovative all human three dimensional liver MPS to faithfully reproduce human physiology and pathology. In the initial iteration, the liver cells are isolated from therapeutic partial hepatectomies, but as this source may be limiting, we are examining induced pluripotent stem cells (iPSC). Currently these iPSC-derived hepatocyte-like cells demonstrate cyp p450 activity and production of fibrinogen and urea through 15 days in our MPS, albeit at levels below fresh human hepatocytes; optimization protocols are underway.

In the first phase of this work we optimized the flow rate and seeding of hepatocytes with non-parenchymal cells (NPCs) from fresh human liver resections. We found that higher flow rates produced poorer tissue formation and increased stress fibers/actin filaments. We maintained functioning hepatocytes in the MPS through 15 days. Hepatocyte function and injury was measured by urea, lactate, AST, ALT, A1AT, fibrinogen and cyp p450 assays. NPCs survived through the 15 day endpoint with immunofluorescent microscopy visualizing leukocytes, endothelial cells and macrophages. The proliferative MDA MB 231 BC cell line showed preliminary evidence of growth attenuation after 12 days of culture in a subpopulation of cells in our MPS. Luminex cancer panel studies are underway with systems biology modeling to describe a communication network in the early microenvironment of micrometastases.

In parallel we are piloting hydrogel scaffolds that support tissue formation but provide a more physiologic rheology; stiff supporting materials yield an inflammatory phenotype in the NPC which forces even well-differentiated BC cells towards a mesenchymal phenotype. We found that hydrogels support hepatocytes through 15 days and incorporate cancer cells. Micropumps are also being developed by Draper Laboratories to allow for physiologic diurnal variations of hormones and nutrients to liver tissues to accurately assess dormancy and chemotherapy response. The completion of these studies will provide insights into the tumor biology of dormant micrometastases and an accessible tool for testing of therapeutics against metastatic BC in a metabolically competent system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-04-08.

Normalization and standardization of electronic health records for high-throughput phenotyping: the SHARPn consortium

RESEARCH OBJECTIVE

To develop scalable informatics infrastructure for normalization of both structured and unstructured electronic health record (EHR) data into a unified, concept-based model for high-throughput phenotype extraction.

MATERIALS AND METHODS

Software tools and applications were developed to extract information from EHRs. Representative and convenience samples of both structured and unstructured data from two EHR systems-Mayo Clinic and Intermountain Healthcare-were used for development and validation. Extracted information was standardized and normalized to meaningful use (MU) conformant terminology and value set standards using Clinical Element Models (CEMs). These resources were used to demonstrate semi-automatic execution of MU clinical-quality measures modeled using the Quality Data Model (QDM) and an open-source rules engine.

RESULTS

Using CEMs and open-source natural language processing and terminology services engines-namely, Apache clinical Text Analysis and Knowledge Extraction System (cTAKES) and Common Terminology Services (CTS2)-we developed a data-normalization platform that ensures data security, end-to-end connectivity, and reliable data flow within and across institutions. We demonstrated the applicability of this platform by executing a QDM-based MU quality measure that determines the percentage of patients between 18 and 75 years with diabetes whose most recent low-density lipoprotein cholesterol test result during the measurement year was <100 mg/dL on a randomly selected cohort of 273 Mayo Clinic patients. The platform identified 21 and 18 patients for the denominator and numerator of the quality measure, respectively. Validation results indicate that all identified patients meet the QDM-based criteria.

CONCLUSIONS

End-to-end automated systems for extracting clinical information from diverse EHR systems require extensive use of standardized vocabularies and terminologies, as well as robust information models for storing, discovering, and processing that information. This study demonstrates the application of modular and open-source resources for enabling secondary use of EHR data through normalization into standards-based, comparable, and consistent format for high-throughput phenotyping to identify patient cohorts.

Effect of bevacizumab on angiogenesis and growth of canine osteosarcoma cells xenografted in athymic mice

Objective-To investigate the effects of bevacizumab, a human monoclonal antibody against vascular endothelial growth factor, on the angiogenesis and growth of canine osteosarcoma cells xenografted in mice. Animals-27 athymic nude mice. Procedures-To each mouse, highly metastasizing parent osteosarcoma cells of canine origin were injected into the left gastrocnemius muscle. Each mouse was then randomly allocated to 1 of 3 treatment groups: high-dose bevacizumab (4 mg/kg, IP), low-dose bevacizumab (2 mg/kg, IP), or control (no treatment). Tumor growth (the number of days required for the tumor to grow from 8 to 13 mm), vasculature, histomorphology, necrosis, and pulmonary metastasis were evaluated. Results-Mice in the high-dose bevacizumab group had significantly delayed tumor growth (mean ± SD, 13.4 ± 3.8 days; range, 9 to 21 days), compared with that for mice in the low-dose bevacizumab group (mean ± SD, 9.4 ± 1.5 days; range, 7 to 11 days) or control group (mean ± SD, 7. 2 ± 1.5 days; range, 4 to 9 days). Mice in the low-dose bevacizumab group also had significantly delayed tumor growth, compared with that for mice in the control group. Conclusions and Clinical Relevance-Results indicated that bevacizumab inhibited growth of canine osteosarcoma cells xenografted in mice, which suggested that vascular endothelial growth factor inhibitors may be clinically useful for the treatment of osteosarcoma in dogs. Impact for Human Medicine-Canine osteosarcoma is used as a research model for human osteosarcoma; therefore, bevacizumab may be clinically beneficial for the treatment of osteosarcoma in humans.

Population-based family history-specific risks for colorectal cancer: a constellation approach

BACKGROUND & AIMS

Colorectal cancer (CRC) risk estimates based on family history typically include only close relatives. We report familial relative risk (FRR) in probands with various combinations, or constellations, of affected relatives, extending to third-degree.

METHODS

A population-based resource that includes a computerized genealogy linked to statewide cancer records was used to identify genetic relationships among CRC cases and their first-, second-, and third-degree relatives (FDRs, SDRs, and TDRs). FRRs were estimated by comparing the observed number of affected persons with a particular family history constellation to the expected number, based on cohort-specific CRC rates.

RESULTS

A total of 2,327,327 persons included in > or =3 generation family histories were analyzed; 10,556 had a diagnosis of CRC. The FRR for CRC in persons with > or =1 affected FDR = 2.05 (95% CI, 1.96-2.14), consistent with published estimates. In the absence of a positive first-degree family history, considering both affected SDRs and TDRs, only 1 constellation had an FRR estimate that was significantly >1.0 (0 affected FDRs, 1 affected SDR, 2 affected TDRs; FRR = 1.33; 95% CI, 1.13-1.55). The FRR for persons with 1 affected FDR, 1 affected SDR, and 0 affected TDRs was 1.88 (95% CI, 1.59-2.20), increasing to FRR = 3.28 (95% CI, 2.44-4.31) for probands with 1 affected FDR, 1 affected SDR, and > or =3 affected TDRs.

CONCLUSIONS

Increased numbers of affected FDRs influences risk much more than affected SDRs or TDRs. However, when combined with a positive first-degree family history, a positive second- and third-degree family history can significantly increase risk.

Iris abscesses with and without intralenticular fungal invasion in the horse

OBJECTIVE

To describe clinical and histologic findings in horses with iris abscesses. Design Retrospective medical records study.

ANIMALS STUDIED

Medical records of horses that had iris abscesses at the University of Florida Veterinary Medical Center, Peterson & Smith Equine Hospital, and Veterinary Eye Specialists of London, Ontario, from 2005 to 2008 were reviewed.

PROCEDURE

Data collected from the medical records included signalment, clinical and histologic descriptions of ocular lesions, therapy, complications, and visual outcomes.

RESULTS

The medical records of two Quarterhorses, one pony, one warmblood, one Westphalian, and one Arab horse with unilateral iris abscesses were identified. Mild-to-severe clinical signs of iridocyclitis were present in all six eyes with iris abscesses. The eyes of two horses with iris abscesses were also associated with deep stromal abscesses and responded to medical therapy alone in one case, and medical therapy and corneal transplantation in the other. Iris abscesses in two horses were also associated with intralenticular invasion due to a Cladosporium and a Fusarium-type fungus respectively, and resulted in enucleations. Two horses with iris abscesses and no apparent lens involvement resolved with medical therapy in one case and surgical removal of the iris abscess and medical therapy in the other.

CONCLUSIONS

This is the first clinical report of iris abscesses in the horse, and the first histologic report of fungal invasion of the horse lens.

Endobronchial polyp derived from a myxosarcoma in the lung of a dog

An endobronchial polyp was visible radiographically and bronchoscopically in an 11-year-old, mixed-breed dog with a persistent cough. The polyp was removed by traction. Initial histological examination suggested it was a myxomatous fibroma. The cough resolved but recurred with polyp regrowth. Two additional lung masses became visible radiographically. The polyp was removed twice more at 6-month intervals. Euthanasia was performed 15 months after first presentation when coughing recurred soon after the final bronchoscopy. Histological examination revealed that the mass was a myxomatous sarcoma. The lung contained two other unrelated tumors: a bronchioloalveolar carcinoma and a carcinoma of unknown origin.

Ideal features for a patient-entered family history and risk assessment tool

Family history (FH) is an important risk factor for many diseases and its assessment can be a powerful tool for identifying and stratifying patients at risk. As part of an initiative to improve FH collection and decision support at Intermountain Healthcare we conducted a literature review on FH data collection and reviewed a number of current Web-based tools. An ideal list of features was produced to help implement goals of the initiative.

Analysis of family health history data collection patterns in consumer-oriented Web-based tools

Current trends have brought resurgent interest in developing consumer-oriented tools that gather patient-entered clinical data. Family health history data has long been recognized as valuable for risk assessment in primary care, but has gained renewed attention recently as part of IT-oriented efforts in personalized medicine. In order to better understand the breadth of data collected in consumer-oriented web applications, we evaluated their collection patterns using the recommendations issued by the American Health Information Community (AHIC).

Spontaneous external biliary fistula in a dog

CASE DESCRIPTION

A 10-year-old sexually intact female dog was examined because of a static, well-circumscribed subcutaneous mass and associated fistulous draining tract located along the right ventrolateral aspect of the thoracic body wall of 15 months' duration.

CLINICAL FINDINGS

Results of computed tomography and fistulography confirmed the presence of the fistulous tract. Computed tomography also revealed a focal, hypodense region in the right ventral portion of the liver that was adjacent to but not clearly associated with the fistulous tract.

TREATMENT AND OUTCOME

Surgical exploration of the tract revealed that it passed into the right hemithorax to the diaphragm; entered the right medial lobe of the liver; and terminated in a well-encapsulated, cystic liver lesion. The right medial liver lobe and all affected tissues were removed. Histologically, the liver lesion consisted of a fibrotic, dilated bile duct. The dilated bile duct and fistula were lined with biliary epithelium. On the basis of these findings, a diagnosis of spontaneous external biliary fistula was made. Five months after surgery, the dog was clinically normal.

CLINICAL RELEVANCE

To the authors' knowledge, spontaneous external biliary fistula in a dog has not been reported in the veterinary medical literature. Despite the rarity of this condition, it should be considered in a dog with similar clinical findings. Clinical findings and results of appropriate diagnostic imaging procedures may provide valuable information in making this diagnosis and in planning surgical treatment.

Amniotic membrane transplantation for corneal surface reconstruction after excision of corneolimbal squamous cell carcinomas in nine horses

OBJECTIVE

The purpose of this study was to evaluate the usefulness and effectiveness of permanent amniotic membrane transplantation as an adjunctive treatment to superficial keratectomy alone or combined with strontium-90 irradiation for treatment of equine corneolimbal squamous cell carcinoma (SCC) to decrease corneal scarring and recurrence rate.

STUDY

The retrospective case study included 11 horses (n = 12 eyes) diagnosed and treated for ocular SCC that involved the limbus and cornea. Nine of those horses (n = 9 eyes) were treated between 2002 and 2006, with superficial lamellar keratectomy alone or combined with strontium-90 irradiation and followed by placement of a permanent amniotic membrane graft in the surgical defect. The level of scarring (i.e. the clarity of the cornea) resulting with the use of amniotic membrane was subjectively compared to cases where a permanent bulbar conjunctival graft was performed following keratectomy combined with strontium-90 irradiation or cryotherapy (n = 3 eyes). Recurrence was defined as the postoperative and postirradiation regrowth of SCC in the same site and globe.

RESULTS

The nine horses that received an amniotic membrane graft after keratectomy alone or combined with irradiation showed a minimal level of scarring in a cornea that regained a greater transparency in comparison to the horses that were treated with a bulbar conjunctival graft. All of the horses that received an amniotic membrane graft had 226 +/- 218 days of follow-up without tumor recurrence (mean +/- SD), ranging from 21 days to 778 days.

CONCLUSIONS

The combination of superficial keratectomy alone or associated with beta-irradiation and permanent amniotic membrane transplantation is an effective treatment of corneal or corneolimbal SCC in horses. The placement of an amniotic membrane material represents an alternative surgical procedure to bulbar conjunctival grafts, especially if there is a lack of bulbar conjunctiva tissue available after tumor resection or if a particularly large corneal resection is necessary. The amniotic membrane is incorporated into the corneal defect and seems to create noticeably much less scarring than a corneal defect covered by bulbar conjunctiva.

Induction of parturition in dairy cattle and its effects on health and subsequent lactation and reproductive performance

OBJECTIVE

To determine the effect of induction of parturition on health, milk production and reproductive performance of dairy cows.

DESIGN

A prospective cohort study in 62 dairy herds.

PROCEDURE

Health, milk production and fertility indices were documented for 1449 dairy cows treated with dexamethasone trimethylacetate, with or without prostaglandin to induce calving. Equivalent data was collected for 603 untreated herd mates that calved at approximately the same time.

RESULTS

The median interval from initial treatment to calving was 11 days. Induction was associated with a substantially lower calf survival and commercial value of surviving calves. Calf viability and value was lower when induced cows were at an earlier stage of pregnancy. Retained foetal membranes, photosensitisation and other problems were significantly more frequent in the induced group compared to the untreated group. Milk production of induced cows was approximately 4% lower than untreated ones, but the majority of reproductive indices were not significantly different between the two groups.

CONCLUSIONS

The practice of induction of parturition in seasonal calving dairy herds is a reliable way of shortening the gestation period of cows. Costs associated with morbidity and mortality of induced cows and losses in lactation and calf production are offset by benefits of improved reproductive performance and more efficient management of the herd. The welfare aspects of induction on calf survival must be considered.

Smart Forms: building condition-specific documentation and decision support tools for ambulatory EHR

Smart Forms are condition-specific documentation tools that integrate pertinent data review, guideline-based decision support, ambulatory order entry, patient education and coded data capture capabilities. Smart Forms are being developed as Web applications in a service oriented architecture and employ a rules engine for dynamic content generation.

An analysis of inpatient nursing communications needs

The health care environment is communications and information intensive. Nurses especially have communications as part of their routine activities, yet little is known about specific nursing communications needs and technologies that might address these needs. This project analyzed the specific communications needs of nurses at Massachusetts General Hospital (MGH) in Boston, MA, through focus group meetings, nursing staff interviews, and direct observation of unit communications. Based on these data, an ideal requirements list for a nursing communication system was created. Data were also gathered and analyzed from units piloting cell phones as nursing communications tools. On non-cell phone units we found that the bulk of communication activity is from the front desk operations associate to the nurse through a sub-optimal overhead paging system that is often unclear or inaudible. The pilot of cellular phones has demonstrated improvements in nursing communications at MGH and there are indications that other emerging technologies will be better able to address the ideal communication needs of nurses.

User-centered development of a Web-based preschool vision screening tool

Although amblyopia is most successfully treated when detected in early childhood, many preschool-aged children are not being screened. This project explored the delivery of Web-based vision screenings, integrated with patient education, to parents and children, aged 3 to 6 years. Through a user-centered design methodology involving requirements gathering, iterative prototype development, and usability testing, a highly usable screening Website was created. Interviewing and testing parents and children in the home were essential in gathering accurate data about environments where the tool would actually be used. Frequent iterations of designing, testing, and modifying the tool were useful in identifying and correcting usability problems. Usability goals were set early in the project, and in the final phase a satisfaction questionnaire was administered to participants. Twenty-one out of 22 final usability objectives were achieved and the feasibility of Web-based vision screening was demonstrated.

Synthesis and biological characterization of .alpha.-(4-fluorophenyl)-4-(5-fluoro-2-pyrimidinyl)-1-piperazinebutanol and analogs as potential atypical antipsychotic agents

A series of 1-(pyrimidin-2-yl)piperazine derivatives were prepared and evaluated in receptor binding assays and in in vivo behavioral paradigms as potential atypical antipsychotic agents. Compound 16 (BMS 181100 (formerly BMY 14802)) emerged as the lead compound from within the series on the basis of its good activity and duration of action in the inhibition of both conditioned avoidance responding and apomorphine-induced stereotopy in the rat. Compound 16 not only failed to induce catalepsy in the rat but was quite effective in reversing the cataleptic effect of neuroleptic agents, thus indicating a low propensity for causing extrapyramidal side effects. In comparison to reference antipsychotic agents, 16 appeared to be less sedating and was relatively weaker in causing muscle incoordination. The compound was essentially inactive in binding to dopamine D2 receptors and its chronic administration to rats did not result in dopamine receptor supersensitivity. It exhibited modest to weak affinity for 5-HT1A and alpha 1 receptors but was found to be a fairly potent ligand for sigma binding sites (IC50 vs (+)-[3H]-3-PPP = 112 nM). Although the resolved enantiomers of racemic 16 did not show dramatic differences from racemate or from each other in most tests, the R(+) enantiomer was up to 11-fold more potent than its antipode in binding to sigma sites. Several studies have indicated that 16 may be a limbic-selective agent which may modulate dopaminergic activity by an indirect mechanism. The compound has been selected for clinical evaluation in the treatment of psychosis.

Buspirone: an anxioselective alternative for the management of anxiety disorders

Buspirone HCl (Buspar) is a novel anxiolytic agent unrelated to the benzodiazepines or other psychotherapeutic agents. Animal studies support an anxioselective profile, i.e. relief of anxiety without sedation, muscle relaxation or anticonvulsant activity. Double-blind clinical studies show buspirone to be effective in the treatment of anxiety and anxiety in the presence of depression. The effects of buspirone on psychomotor function, physical dependence and abuse potential tests are similar to those seen with placebo treatments. Mechanism of action studies indicate activity in a variety of neuronal systems.

Discriminative stimulus characteristics of BMY 14802 in the pigeon

Pigeons were trained to discriminate intramuscular injections of 5.6 mg/kg BMY 14802, a drug that has relatively high affinity for sigma binding sites, from saline in a two-key operant procedure. Many compounds that displace sigma binding failed to produce BMY 14802-like discriminative stimulus effects; these included (+)-SKF 10,047, (+)3-PPP, DTG and MR 2035; the typical antipsychotic haloperidol; the putative antipsychotics tiospirone, cinuperone and rimcazole; and the uncompetitive NMDA antagonist phencyclidine. In addition, MR 2035 and tiosperone failed to antagonize the discriminative stimulus effects of BMY 14802. The selective D2 antagonist eticlopride and the norepinephrine uptake blocker and antidepressant desmethylimipramine also failed to evoke substantial BMY 14802-appropriate responding. In contrast to sigma ligands and other reference compounds, the 5-HT1A agonists buspirone, 8-OH-DPAT and spiroxatrine dose-dependently produced BMY 14802-like discriminative stimulus effects. The limited-efficacy 5-hydroxytryptamine (HT)1A agonist NAN 190 did not produce BMY 14802-like discriminative effects; however, it did competitively antagonize the stimulus effects of BMY 14802 and the BMY 14802-like stimulus effects of (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin. Other serotonergic compounds failed to produce substantial BMY 14802-appropriate responding; such as 5-HT1 agonist I-5-HTP; 5-HT1A/1B agonist RU24969; 5-HT1B/1C agonist m-CPP; 5-HT1C/2 agonist quipazine; 5-HT1C/2 antagonists, metergoline and the atypical antipsychotic clozapine; and 5-HT3 antagonist ondansetron. Also, metergoline, ondansetron and pirenpirone failed to antagonize the stimulus effects of BMY 14802. These results indicate that the discriminative stimulus effects of BMY 14802 are serotonergically mediated primarily by 5-HT1A receptors rather than by sigma sites.

An information infrastructure for long-term care

Emerging trends promise to alter the way long-term care is practiced. These include: changing regulation of the nursing home industry with emphasis on outcome and assessment, a trend in medical informatics away from expert systems and toward on-line decision support and reminder systems, and the application of industrial statistical quality management techniques to the realm of human services. Emerging standards such as the Arden Syntax and Unified Medical Language Systems and technologies such as Rapid Application Development Tools will facilitate the use of modern computing to mold and implement these converging trends.

Traceable values for nitrate in water samples by isotope dilution analysis using a small thermionic quadrupole mass spectrometer

An isotope dilution mass spectrometric procedure was developed for the determination of nitrate in water samples. The isotope dilution experiments were carried out using the Institute for Reference Materials and Measurements's 15N-enriched nitrate spike reference material IRMM-627. Nitrate was isolated from the matrix by precipitating it as nitron nitrate, from which emission of negative thermal NO2-ions was found to be best. The ions were produced in the ion source of a small, low-cost, easy-to-handle thermionic quadrupole mass spectrometer equipped with a secondary electron multiplier coupled to an ion counter. The procedure developed was applied to the measurement of nitrate in a certified reference material (stimulated rainwater, CRM 409 from Community Bureau of Reference), in sparkling mineral water, and in tap water. Results were compared with those obtained using ion chromatography. Good agreement (within 1%) was found between the concentration determined by isotope dilution mass spectrometry, the values from ion chromatography, and the certified value. The procedure developed allowed accurate and traceable determinations of nitrate in water samples, with an expanded uncertainty (coverage factor k = 2) of 2-5%, and the detection limit was found to be 2 mumol kg-1.

Apoplastic pH in corn root gravitropism: a laser scanning confocal microscopy measurement

The ability to measure the pH of the apoplast in situ is of special interest as a test of the cell wall acidification theory. Optical sectioning of living seedlings of corn roots using the laser scanning confocal microscope (LSCM) permits us to make pH measurements in living tissue. The pH of the apoplast of corn roots was measured by this method after infiltration with Cl-NERF, a pH-sensitive dye, along with Texas Red Dextran 3000, a pH-insensitive dye, as an internal standard. In the elongation zone of corn roots, the mean apoplastic pH was 4.9. Upon gravitropic stimulation, the pH on the convex side of actively bending roots was 4.5. The lowering of the apoplastic pH by 0.4 units appears to be sufficient to account for the increased growth on that side. This technique provides site-specific evidence for the acid growth theory of cell elongation. The LSCM permits measurements of the pH of living tissues, and has a sensitivity of approximately 0.2 pH units.

Pharmacology and neurochemistry of nefazodone, a novel antidepressant drug

Nefazodone is a new antidepressant drug with a pharmacologic profile distinct from that of the tricyclic, monoamine oxidase inhibitor, and serotonin selective reuptake inhibitor antidepressants. Nefazodone was initially discovered for its ability to block 5-HT2A receptors and its reduced potency as an alpha 1-adrenergic blocker. It was later shown to inhibit both serotonin and norepinephrine uptake in vitro, attributes which most likely impart its clinical efficacy and which differentiate nefazodone from its chemical predecessor trazodone. The combination of these two mechanisms may ultimately result in a facilitation of 5-HT1A-mediated neurotransmission, which may be beneficial for treating symptoms of depression as evidenced by recent clinical findings. In addition, the preclinical profile of nefazodone demonstrates that it has decreased anticholinergic and antihistaminic activity relative to traditional agents. Clinical findings to date are consistent with these observations.

BMY 14802, a sigma receptor ligand for the treatment of schizophrenia

The theoretical role of sigma receptors in psychosis has led to the development of selective sigma receptor ligands as potential antipsychotic agents. BMY 14802 has its most potent binding at the sigma binding site, with some degree of serotonin subtype 1A and negligible dopamine receptor binding. It is atypical of standard neuroleptics in that it does not induce catalepsy in rats. It has been shown to have efficacy in animal models of psychosis. It was hypothesized that the drug would have antipsychotic effects in humans without producing the extrapyramidal side effects typical of standard neuroleptics. We report here the results of an uncontrolled, multicenter safety and efficacy study of patients with acute exacerbations of schizophrenia treated with BMY 14802. After 1 week of single-blind placebo treatment, 28 patients were treated with BMY 14802 (up to 3000 mg/day) for up to 4 weeks. There was no significant improvement in psychiatric symptoms, as measured by the total Brief Psychiatric Rating Scale scores or Clinical Global Improvement. There were no changes in involuntary movements, as measured by the Abnormal Involuntary Movement Scale, or in extrapyramidal symptoms as measured by the Simpson-Angus Scale.

Soluble forms of the human T cell receptor CD4 are efficiently expressed by Streptomyces lividans

We have developed a new gene expression and secretion system for Streptomyces lividans and used it to produce soluble forms of a human T-cell receptor CD4 at levels greater than 300 mg/l. The system uses the transcription, translation and secretion signals of the serine protease inhibitor gene STI-II which is naturally produced by S. longisporus. Using these signals, soluble derivatives of CD4 were secreted directly into the culture supernatant as correctly processed soluble, biologically active proteins. High level expression of the CD4 proteins depended on the transcription initiation signal, the amino acid sequence surrounding the signal peptide cleavage site and temporally controlled protease activities. We discuss these results in the context of the potential of this system for producing other eukaryotic proteins in Streptomyces.

Synthesis and PET studies of fluorine-18-BMY 14802: a potential antipsychotic drug

BMY 14802 is a compound containing fluorine developed as a potential antipsychotic drug. It has a moderate affinity for the sigma binding site and a very low affinity for dopamine D2 receptors and has been predicted to have antipsychotic properties without the side effect potential of existing drugs. To assess the brain uptake, pharmacokinetics, stereoselectivity and binding properties of this potential antipsychotic drug, enantiomerically pure samples of (-) and (+)-[18F]BMY 14802 were examined in a baboon with PET. A tissue distribution with racemic labeled BMY 14802 was also carried out in mice. Radiochemical yields of 15% at the end of bombardment (EOB) for the racemic mixture, and 5% for each enantiomer with a specific activity of 2-5 Ci/mumol at EOB were obtained. In baboons, [18F]BMY 14802 cleared rapidly from the plasma and the glucuronidated [18F]BMY 14802 appeared. Radioactivity peaked (0.04-0.07% dose/cc) in all areas of the brain examined at about 5 min postinjection. It then rapidly cleared to about 30% of peak value by 20 min postinjection and to less than 10% of peak by 60 min postinjection in all regions. A similar rapid clearance from brain was also observed in mice. Pretreatment with unlabeled BMY 14802 (7 mg/kg), did not produce the expected reductions in distribution volume and clearance halftimes consistent with receptor binding. Although the rapid kinetics of [18F]BMY 14802 made it difficult to resolve the processes of transport and binding of the labeled drug, the lack of regional distribution consistent with the known distribution of sigma binding sites as well as the lack of stereoselectivity suggest that the behavior of BMY 14802 in the brain is dominated by its transport properties in tissue rather than its binding to sigma sites. Moreover, its rapid clearance from brain may be a limiting factor in its use as an antipsychotic drug.