Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti

Electronic health information systems, including electronic medical records (EMRs), have the potential to improve access to information and quality of care, among other things. Success factors and challenges for novel EMR implementations in low-resource settings have increasingly been studied, although less is known about maturing systems and sustainability. One systematic review identified seven categories of implementation success factors: ethical, financial, functionality, organizational, political, technical and training. This case study applies this framework to iSanté, Haiti's national EMR in use in more than 100 sites and housing records for more than 750 000 patients. The author group, consisting of representatives of different agencies within the Haitian Ministry of Health (MSPP), funding partner the Centers for Disease Control and Prevention (CDC) Haiti, and implementing partner the International Training and Education Center for Health (I-TECH), identify successes and lessons learned according to the seven identified categories, and propose an additional cross-cutting category, sustainability. Factors important for long-term implementation success of complex information systems are balancing investments in hardware and software infrastructure upkeep, user capacity and data quality control; designing and building a system within the context of the greater eHealth ecosystem with a plan for interoperability and data exchange; establishing system governance and strong leadership to support local system ownership and planning for system financing to ensure sustainability. Lessons learned from 10 years of implementation of the iSanté EMR system are relevant to sustainability of a full range of increasingly interrelated information systems (e.g. for laboratory, supply chain, pharmacy and human resources) in the health sector in low-resource settings.

Gamma-Secretase, ErbB4 nuclear localization and neuregulin expression correlates with prostate cancer patient clinical outcome

10587

Background: Membrane protein ErbB4 is a member of ErbB growth factor receptor family, which can be activated by neuregulins (NRG). Upon neuregulin activation, ErbB4 is cleaved within its transmembrane domain by presenilin γ-secratase (PSN) to release an intracellular domain that translocates into the nucleus. Although, ErbB4 ligand-dependant translocation of ErbB4 to the nucleus and its nuclear activity has been reported in breast cancer cell lines, there are few reports concerning ErbB4 nuclear localization and its clinical relevance. Here, we report for the first time the clinical relevance of ErbB4 nuclear localization, NRG, and PSN expression in prostate cancer tissues. Methods: Immunostaining using anti-ErbB4, anti-PSN2 and anti-neuregulin antibodies was done on a set of tissue microarrays (TMA) from 140 patients. The TMAs contained, 92 cores of normal prostate tissue obtained from 46 autopsy specimens from young males, 373 tumor and normal adjacent cores from 63 hormone sensitive PCa (HSPCa) patients, and 146 cores from 31 hormone refractory PCa (HRPCa) patients. Results: We found a statistically significant increase (p<0.01) in the percentage of ErbB4 nuclear localization (68.7% vs 53.2%), NRG expression (2.06 vs 1.41) and PSN2 expression (2.14 vs 1.53) when comparing cancerous tissues to normal tissue adjacent to cancer. Interestingly, a similar statistically significant increase in nuclear ErbB4 and NRG expression was observed when comparing HRPCa to HSPCa (p<0.001). In cancerous tissues, a strong correlation was found between nuclear ErbB4 and NRG expression (r=0.672), between nuclear ErbB4 and PSN2 expression (r=0.51), and between PSN2 and NRG expression (r=0.71). Nuclear ErbB4 and PSN2 inversely correlated with tumor stage and lymph node invasion. Kaplan Meier analysis of nuclear ErbB4 (p=0.030) and PSN2 expression (p=0.018) showed an inverse association with biochemical recurrence (BCR) of PCa. In multivariate analyses including these three markers and clinical parameters, only nuclear ErbB4 retained an independent prognosis value. Conclusion: Our results suggest that high nuclear ErbB4 along with increased PSN2 expression have a protective effect against prostate cancer progression and BCR.

No significant financial relationships to disclose.

Use of nuclear androgen receptor status to predict early biochemical recurrence of prostate cancer patients

21073

Background: Prostate cancer (PCa) is a leading cause of cancer death in North American men. The androgen receptor (AR) has an established role in the progression of this disease; however, it is unclear at what stage it intervenes. It is also uncertain whether the AR can be a useful prognostic marker for PCa. In this study, we assessed AR expression and sub-cellular localization in normal prostate as well as in androgen sensitive and insensitive PCa (AIPCa) tissues, and evaluated the ability of the AR to predict biochemical recurrence (BCR). Methods: We used tissue micro-arrays containing prostate tissue cores obtained from cancer-free patients (n=43), AIPCa patients (n=36), and patients with hormone-sensitive cancers (n=64) from which were collected both cancerous and normal adjacent tissue. Using immmunohistochemistry, we stained the tissue micro-arrays with a monoclonal antibody recognizing the AR. Two observers assessed the frequency and intensity of both cytoplasmic and nuclear AR staining. AR cytoplasmic (Ci) and nuclear (Ni) indices were calculated by multiplying nuclear staining frequency and nuclear staining intensity. Kaplan Meier, and Cox multivariate analyses were done using SPSS. Results: We found that AR Ci increased significantly in AIPCa although a modest but significant increase in PCa Ci was observed compared to normal tissues. In contrast, AR Ni was significantly lower in cancer-free patients as opposed to that seen in normal tissue adjacent to cancer. Similarly, cancerous tissue exhibited higher AR Ni than its adjacent normal tissue (p<0.05, Kruskal-Wallis). Kaplan Meier analyses revealed that low AR Ni was predictive of an early onset of BCR (before 3-years) in the sub-cohort of hormone-sensitive patients (LR=6.51, p=0.011). Futhermore, low AR Ni remained an independent predictor of early BCR in a Cox multivariate model controlling for age, pre-operative PSA, lymph node invasion, Gleason score and surgical margin status (HR=2.28, 95% CI=1.04 - 5, p<0.05). Conclusions: We conclude that increased nuclear AR activity could be a pre-malignant step in PCa progression whereas its role within cancer cells may be more complex, as low AR nuclear activity was associated with early onset of BCR.

No significant financial relationships to disclose.

A ligand-independent androgen receptor function protects from inositol hexakisphosphate-induced cell death

14566

Background: The androgen receptor (AR) is often aberrantly expressed or activated in hormone-refractory (HR) prostate cancer (PCa). Though it is not clear whether this is directly linked to AR expression, various cell survival pathways are over-activated in HR-PCa, which is characterized by its poor clinical outcome and resistance to available therapies. Inositol hexakisphosphate (IP6) is a phytochemical anti-cancer agent, which we have found to be more effective in PCa cell lines that do not express the AR. Our goal was to address the mechanism of IP6-induced cell death and to evaluate if and how the AR may interfere with its activity. Methods: We used LNCaP, DU145, 22Rv1 as well as wild-type PC3 and AR-expressing PC3 (PC3AR) cell lines to assess the metabolic toxicity of IP6 by WST-1 assay in normal, androgen-supplemented, and androgen-depleted cell culture conditions. A siRNA targeting the androgen receptor (AR) was used to control for genuine AR-mediated effects in the PC3/PC3AR cell lines. Apoptosis was quantified using fluorogenic caspase-3 assays as well as quantitative DNA fragmentation assays. Expression of a variety of genes involved in apoptosis and cell survival pathways was evaluated by real time PCR. Results: While the activity of IP6 was not modulated by the presence of androgens for any cell line, PC3AR cells were significantly more resistant to IP6 than wild-type PC3 cells according to WST-1, caspase-3 and DNA fragmentation assays (p < 0.05). Down-regulation of the AR in the PC3AR cell line resulted in increased metabolic toxicity of IP6 on these cells (p < 10−5). Although treatment with IP6 resulted in the up-regulation of the pro-apoptotic genes Puma, Noxa, as well as of IRF-2 and IkB-αλπηα in PC3 cells, this did not occur in PC3AR cells (p < 0.05). Conclusion: We conclude that, at least in PC3/PC3AR, cells IP6 sensitivity is linked to a ligand-independent function of the AR. To our knowledge, this is the first report of a ligand-independent AR function involved in resistance to a cytotoxic compound. Establishing the molecular details of this novel function is a major part of our ongoing research.

No significant financial relationships to disclose.

Regulation of IKKe expression by androgen receptor and NF-kB transcriptional factor in prostate cancer

10106

Background: In unstimulated cells, NF-kB transcription factor is sequestered in the cytoplasm as an inactive p65/p50 dimer through interaction with a member of the inhibitor of kB protein family (IkBa). Prominent constitutive activation of NF-kB was observed in prostate cancer (PCa) cell lines lacking androgen receptor (AR) expression (PC3 and DU145) whereas only very low levels of NF-kB activity were seen in androgen-dependent cell lines (LNCaP and CWR22Rv1). As IkB kinase-e (IKKe) has recently been shown to be controlled by NF-kB, we hypothesize that IKKe may be involved in PCa progression based on its interaction with the NF-kB protein, and that these interactions are influenced by AR signaling. Methods: LNCaP cells were used to study IKKe expression with or without stimulation by the analog of androgen R1881 and by the tumor necrosis factor (TNF)-a. IKKe protein and RNA expression were characterized by immunoblot assay and quantitative PCR, respectively. IKKe expression was then correlated with p65 nuclear localisation. NF-kB activity was inhibited using an IkBa dominant negative construction. Inhibition of AR synthesis was performed using a siRNA against AR. Results: IKKe gene expression was stimulated by TNF-a treatment in LNCaP cells and inhibited by transfection of a dominant negative form of IkBa which prevented the nuclear translocation of p65. We also observed constitutive IKKe expression in hormone-refractory cells. Furthermore, we showed that TNF-a-induced IKKe expression is inhibited by R1881 in hormone-responsive PCa cells and this inhibition was correlated with the modulation of IkBa expression by R1881. Finally, we observed that the expression of IKKe is constitutively induced after blocking AR expression in LNCaP cells. Conclusions:. Our results show that IKKe expression is regulated by NF-kB in PCa cell lines. Moreover, IKKe appears to be down-regulated by ligand-dependent AR signaling through the control of IkBa expression. Further studies will be needed in order to determine the implications of this phenomenon with regard to NF-kB regulation, androgen resistance and effect on PCa progression.

No significant financial relationships to disclose.

[Congenital rubella: a case report]

Rubella is an innocuous illness in adult unless it is contracted by a pregnant woman. We recently observed a case of congenital rubella in the department of neonatology of Abass Ndao hospital in Dakar. It's a female new-born, born after 40 week gestation, with a well followed pregnancy. The first clinical examination shows a severe intrauterine growth retardation and bilateral comeal opacity. Maternal and new-born serologic confirmation is obtained with positive rubella specific IgM and IgG. We also find severe ocular pathology, hearing deficit and associated cardiac disease. This case shows the needs for preventive strategies, such as vaccination against rubella for women of child bearing age.

Selected P. falciparum specific immune responses are maintained in AIDS adults in Burkina Faso

In tropical areas where Plasmodium falciparum malaria is endemic, co-infection with HIV-1 does not lead to a worsening of malaria, raising questions about the immunological interactions between both infections. Alterations of immune response to malaria during HIV-1 infection was investigated in the town of Bobo Dioulasso, Burkina Faso. Sixty-six adults were enrolled, including 37 HIV-1 positive subjects with < 250 CD4+ cells/microliter and clinical AIDS, and 29 HIV-1, negative healthy subjects. In vitro lymphocyte proliferation and cytokine (IFN-gamma, IL-2 and IL-4) production were assessed in isolated mononuclear cells (PBMC) in presence of PHA, PPD or three malarial antigens: the baculovirus-expressed protein from P. falciparum Merozoite Surface Protein-I, a P. falciparum in vitro culture and a crude schizont extract. Compared with healthy subjects. AIDS patients presented with decreased levels of cell proliferation and of IFN-gamma and IL-2 production, in response to all antigens except the schizont extract. Similar levels of IL-4 production were obtained in both groups. Mitogenic stimulation of whole blood cultures was also performed, and revealed similar trends in cytokine production as in PBMC cultures. These results show that some components of the specific human immune responses to falciparum parasites may not be modified during AIDS, in spite of the strong cellular alterations induced by HIV, namely the decrease of the CD4+ lymphocyte subset.