Designing and Implementation of a Digitalized Intersectoral Discharge Management System and Its Effect on Readmissions: Mixed Methods Approach

BACKGROUND

Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital.

OBJECTIVE

This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate.

METHODS

A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group.

RESULTS

Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20).

CONCLUSIONS

This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

A222 BILIARY ATRESIA IN BRITISH COLUMBIA: THE ROLE OF REFERRAL AGE AND DIAGNOSITIC EVALUATION ON OUTCOME

Background

Biliary atresia (BA), a newborn liver disease, is the leading cause of cirrhosis and liver-related death in children and the most common indication for pediatric liver transplantation (LT). The current standard of BA care is sequential surgery with an initial Kasai hepatoportoenterostomy (KP), followed by LT for those who progress to liver failure. Survival with native liver (SNL) correlates to infant age at KP with best outcome at early KP at <30 days of age. Novel screening tests and diagnostic algorithms have been proposed, however the variability of clinical presentation and lack of a diagnostic test challenge early diagnosis and timely KP.

Aims

To assess age at BA presentation and subsequent investigations to the timing of KP and outcome.

Methods

A retrospective study of all BA cases referred to BC Children’s Hospital January 1, 2000-December 31, 2018. Data collection included age at referral, clinical presentation, laboratory and imaging studies, age at KP and LT. SNL and overall survival rates were determined. Descriptive statistics and data analyses using SSPS were applied.

Results

In this 19-year study, there were 48 cases (58% female) of BA in BC (1:17,000 live births). KP was performed in 41 patients and 7 had primary LT. Following the initial KP, 23 cases had LT. Median age at presentation decreased from 55 to 42 days after introduction of the BC BA stool card screening program in 2014. The Median (IQR) age at KP was 62 days (48–87). Median delay from the age at first encounter to the KP was 10 days (4–21); early referral (youngest 3^rd of cohort) had a mean delay to KP of 25 days (15–40) compared with the late group (oldest 3^rd of cohort) with median delay to KP of 5 days (1–8). There were 2.4 and 1.4 investigations/patient before undergoing KP in the youngest and oldest age at presentation cohorts. HIDA scan was done in 41% and 19% of the youngest and oldest presentation cohorts respectively. Median LT age was 9.6 months (8-13months). Median age at KP for patients who received LT was 77 days (53–92), compared to 52 days (41–79) in those without LT (p=0.08). All KPs were completed by 7 surgeons, each completing 1- 10 KPs. Overall patient survival and SNL were 98% and 37.5%.

Conclusions

In this cohort, SNL rates were below SNL rates in other national studies. SNL rates were higher in patients who underwent KP at a younger age, and early findings from a provincial screening program show a shift in age at presentation, potentially owing in part to increased community awareness of BA. A diagnostic algorithm that accounts for age at presentation is needed achieve timely KP.

Funding Agencies

None

A59 SEVERE CHEMOTHERAPY-INDUCED SECRETORY DIARRHEA

Background

Diarrhea is one of the most common side effects of chemotherapy, estimated to occur in up to 40% of all patients undergoing cancer therapy. Non-complicated chemotherapy-induced diarrhea (CID) can be managed with loperamide, whereas complicated CID should be treated with continuous infusion of octreotide. Octreotide is usually effective within 48hs of administration. Options for patients that do not respond to loperamide or octreotide include atropine, oral budesonide and cholestyramine.

Aims

To describe the case of an 18 yo girl with acute myeloid leukemia (AML) who developed severe secretory diarrhea during her treatment course.

Methods

Retrospective case report.

Results

The patient was initially treated with Cytarabine, Daunorubicin and Etoposide, and on her third cycle, Gemtuzumab was added. Four weeks later she presented with watery diarrhea up to 6 L/day. She continued with high output despite no oral intake, which was consistent with secretory diarrhea. Infectious workup was negative, and she received Loperamide. Her output decreased to 1 L for 2 days but then increased again to 6 L. She deteriorated and loperamide was switched to octreotide 0.8mcg/Kg/h. The dose was increased to 1.2mcg/Kg/h and she presented blood in the stools. Her stool output was still 4 L/day and octreotide was stopped after one week. Flex sigmoidoscopy showed proctocolitis with friability. Biopsy showed architectural distortion with loss of the superficial epithelium. She was emotionally distressed due to many days of no oral intake, hence Pediasure peptide was introduced, with no changes in the output. Rice was introduced but her diarrhea worsened, and oral intake was stopped again. Four weeks after the onset of diarrhea, her stool output was still above 2 L/day, and cholestyramine 4g once daily was started. Four days later her output decreased and diet was slowly introduced. Two weeks later she had a normal stool output. Cholestyramine was stopped and she was discharged home.

Finding the culprit for this case is a challenge, but important to avoid this drug in the future as prior history of CID is a risk factor for a new-onset. Gemtuzumab is a relatively new anti-CD33 antibody used in AML, and results from a meta-analysis showed that adding it to induction chemotherapy may increase the incidence of diarrhea. Her diarrhea started four weeks after the dose of Gemtuzumab, and we believe this new agent might have played an important role in her case. To our knowledge, there are no cases in the literature associating Gemtzumab with such prolonged and severe diarrhea.

Conclusions

This was a challenging case of CID that did not respond to Loperamide or octreotide and caused a lot of emotional distress for the patient and her providers. Since she responded well to cholestyramine, we recommend its use when the loperamide and octreotide have failed, or in addition to octreotide in severe cases.

Funding Agencies

None

Thrombosen im Kindesalter

Thrombosen im Kindesalter sind häufiger als bisher vermutet. Eine 1990 durchgeführte grob orientierende Umfrage in den Kinderkliniken der BRD (ohne ehemalige DDR) ergab für die vorangegangenen 12 Monate etwa 200 Thrombosen, davon ca. zwei Drittel venöse, ca. ein Drittel arterielle und disseminierte.

Thrombosen bei Säuglingen und Kindern weisen folgende Besonderheiten auf: Erstmanifestation von hereditären Thrombophilien, wie z.B. der Purpura fulminans beim homozygoten Protein-C- und Protein-S-Mangel; Thrombophilie bei pädiatrischen Krankheitsbildern, wie kongenitale zyanotische Herzfehler, Kawasaki-Syndrom, hämolytisch-urämisches Syndrom ; unterschiedliche Erscheinungsformen, z.B. beim systemischen Lupus erythematodes des Erwachsenen vorwiegend Thrombosen, beim Kind dagegen vorwiegend Blutungen; keine arteriosklerotischen Gefäßveränderungen, dafür aber erhöhte Gefäßpermeabilität bei Frühgeborenen; der Pädiater muß mit den altersspezifischen Normalwerten von antithrombotischen Faktoren, die besonders beim Neugeborenen erheblich von der Erwachsenennorm abweichen, vertraut sein, und er muß mit geringen Blutmengen zur Diagnosestellung und Verlaufskontrolle auskommen.

Building a Privacy, Ethics, and Data Access Framework for Real World Computerised Medical Record System Data: A Delphi Study. Contribution of the Primary Health Care Informatics Working Group

BACKGROUND

Privacy, ethics, and data access issues pose significant challenges to the timely delivery of health research. Whilst the fundamental drivers to ensure that data access is ethical and satisfies privacy requirements are similar, they are often dealt with in varying ways by different approval processes.

OBJECTIVE

To achieve a consensus across an international panel of health care and informatics professionals on an integrated set of privacy and ethics principles that could accelerate health data access in data-driven health research projects.

METHOD

A three-round consensus development process was used. In round one, we developed a baseline framework for privacy, ethics, and data access based on a review of existing literature in the health, informatics, and policy domains. This was further developed using a two-round Delphi consensus building process involving 20 experts who were members of the International Medical Informatics Association (IMIA) and European Federation of Medical Informatics (EFMI) Primary Health Care Informatics Working Groups. To achieve consensus we required an extended Delphi process.

RESULTS

The first round involved feedback on and development of the baseline framework. This consisted of four components: (1) ethical principles, (2) ethical guidance questions, (3) privacy and data access principles, and (4) privacy and data access guidance questions. Round two developed consensus in key areas of the revised framework, allowing the building of a newly, more detailed and descriptive framework. In the final round panel experts expressed their opinions, either as agreements or disagreements, on the ethics and privacy statements of the framework finding some of the previous round disagreements to be surprising in view of established ethical principles.

CONCLUSION

This study develops a framework for an integrated approach to ethics and privacy. Privacy breech risk should not be considered in isolation but instead balanced by potential ethical benefit.

Evidence for the role of microRNA 374b in acquired cisplatin resistance in pancreatic cancer cells

Recent evidence has implicated microRNAs (miRNAs) as potentially significant players in the acquisition of cancer-drug resistance in pancreatic and other cancers. To evaluate the potential contribution of miRNAs in acquired resistance to cisplatin in pancreatic cancer, we compared levels of more than 2000 human miRNAs in a cisplatin-resistant cell line (BxPC3-R) derived from parental (BxPC3) cells by step-wise exposure to increasing concentrations of the drug over more than 20 passages. The acquired drug resistance was accompanied by significant changes in the expression of 57 miRNAs, of which 23 were downregulated and 34 were upregulated. Employing a hidden Markov model (HMM) algorithm, we identified downregulation of miR-374b as likely being directly involved in acquisition of the drug-resistant phenotype. Consistent with this prediction, ectopic overexpression of miR-374b in the resistant BxPC3-R cells restored cisplatin sensitivity to levels approaching those displayed by the BxPC3 parental cells. The results are consistent with a growing body of evidence implicating miRNAs in acquired cancer-drug resistance and with the potential therapeutic value of these small regulatory RNAs in blocking and/or reversing the process.

Anoctamin 6 is localized in the primary cilium of renal tubular cells and is involved in apoptosis-dependent cyst lumen formation

Primary cilia are antenna-like structures projected from the apical surface of various mammalian cells including renal tubular cells. Functional or structural defects of the cilium lead to systemic disorders comprising polycystic kidneys as a key feature. Here we show that anoctamin 6 (ANO6), a member of the anoctamin chloride channel family, is localized in the primary cilium of renal epithelial cells in vitro and in vivo. ANO6 was not essential for cilia formation and had no effect on in vitro cyst expansion. However, knockdown of ANO6 impaired cyst lumen formation of MDCK cells in three-dimensional culture. In the absence of ANO6, apoptosis was reduced and epithelial cells were incompletely removed from the center of cell aggregates, which form in the early phase of cystogenesis. In line with these data, we show that ANO6 is highly expressed in apoptotic cyst epithelial cells of human polycystic kidneys. These data identify ANO6 as a cilium-associated protein and suggest its functional relevance in cyst formation.

Divergent effects of the 'biased' 5-HT1 A receptor agonists F15599 and F13714 in a novel object pattern separation task

BACKGROUND AND PURPOSE

Pattern separation, that is, the formation of distinct representations from similar inputs, is an important hippocampal process implicated in cognitive domains like episodic memory. A deficit in pattern separation could lead to memory impairments in several psychiatric and neurological disorders. Hence, mechanisms by which pattern separation can be increased are of potential therapeutic interest.

EXPERIMENTAL APPROACH

5-HT1A receptors are involved in spatial memory. Herein we tested the 'biased' 5-HT1A receptor agonists F15599, which preferentially activates post-synaptic heteroreceptors, and F13714, which preferentially activates raphe-located autoreceptors, in rats in a novel spatial task assessing pattern separation, the object pattern separation (OPS) task.

KEY RESULTS

The acetylcholinesterase inhibitor donepezil, which served as a positive control, significantly improved spatial pattern separation at a dose of 1 mg·kg(-1) , p.o. F15599 increased pattern separation at 0.04 mg·kg(-1) , i.p., while F13714 decreased pattern separation at 0.0025 mg·kg(-1) , i.p. The selective 5-HT1A receptor antagonist WAY-100635 (0.63 mg·kg(-1) , s.c.) counteracted the effects of both agonists. These data suggest that acute preferential activation of post-synaptic 5-HT1A heteroreceptors improves spatial pattern separation, whereas acute preferential activation of raphe-located 5-HT1A autoreceptors impairs performance.

CONCLUSIONS AND IMPLICATIONS

We successfully established and validated a novel, simple and robust OPS task and observed a diverging profile of response with 'biased' 5-HT1A receptor agonists based on their targeting of receptors in distinct brain regions. Our data suggest that the post-synaptic 5-HT1A receptor consists of a potential novel molecular target to improve pattern separation performance.

Computerized provider order entry reduces length of stay in a community hospital

OBJECTIVE

Does computerized provider order entry (CPOE) improve clinical, cost, and efficiency outcomes as quantified in shortened hospital length of stay (LOS)? Most prior studies were done in university settings with home-grown electronic records, and are now 20 years old. This study asked whether CPOE exerts a downward force on LOS in the current era of HITECH incentives, using a vendor product in a community hospital.

METHODS

The methodology retrospectively evaluated correlation between CPOE and LOS on a perpatient, per-visit basis over 22 consecutive quarters, organized by discipline. All orders from all areas were eligible, except verbals, and medication orders in the emergency department which were not available via CPOE. These results were compared with quarterly case mix indices organized by discipline. Correlational and regression analyses were cross-checked to ensure validity of R-square coefficients, and data were smoothed for ease of display. Standard models were used to calculate the inflection point.

RESULTS

Gains in CPOE adoption occurred iteratively house-wide, and in each discipline. LOS decreased in a sigmoid shaped curve. The inflection point shows that once CPOE adoption approaches 60%, further lowering of LOS accelerates. Overall there was a 20.2% reduction in LOS correlated with adoption of CPOE. Case mix index increased during the study period showing that reductions in LOS occurred despite increased patient complexity and resource utilization.

CONCLUSIONS

There was a 20.2% reduction in LOS correlated with rising adoption of CPOE. CPOE contributes to improved clinical, cost, and efficiency outcomes as quantified in reduced LOS, over and above other processes introduced to lower LOS. CPOE enabled a reduction in LOS despite an increase in the case mix index during the time frame of this study.

Calcium-activated and apoptotic phospholipid scrambling induced by Ano6 can occur independently of Ano6 ion currents

Immune cells and platelets maintain plasma membrane phospholipid asymmetry. Upon activation, this asymmetry is disrupted by phospholipid scrambling (PS), which is a major step during activation of immune cells, hemostasis and apoptosis. Anoctamin 6 (Ano6; TMEM16F) causes chloride (Cl(-)) and cation currents and is required for Ca(2+)-dependent PS. It is defective in blood cells from patients with Scott syndrome, a rare bleeding disorder. We examined if Cl(-) currents and PS are related, whether both processes are Ca(2+) dependent, and whether Ca(2+)-independent scrambling during intrinsic and extrinsic apoptosis is controlled by Ano6. Ca(2+) increase by ionomycin activated Ano6 Cl(-) currents and PS in normal lymphocytes, but not in B-lymphocytes from two different patients with Scott syndrome. Fas ligand (FasL) did not increase intracellular Ca(2+), but activated Cl(-) currents in normal but not in Scott lymphocytes. Whole-cell currents were inhibited by Cl(-) channel blockers and by siRNA knockdown of Ano6. In contrast, intrinsic mitochondrial apoptosis by ABT-737 did not induce Cl(-) currents in lymphocytes. PS was not inhibited by blockers of Ano6 or removal of Cl(-) ions. Remarkably, Ca(2+)-independent scrambling due to extrinsic (FasL) or intrinsic (ABT-737) apoptosis was unchanged in Scott cells. We conclude that: (i) Ano6 Cl(-) currents are activated by increase in cytosolic Ca(2+), or Ca(2+) independent by stimulation of Fas receptors; (ii) Ca(2+)-dependent PS induced by Ano6 does not require Cl(-) currents; (iii) Ca(2+)-independent PS does not require Ano6; (iv) Ano6 is necessary for Ca(2+)-dependent PS, but not by increasing intracellular Ca(2+).

CYBA C242T polymorphism is associated with obesity and diabetes mellitus in Brazilian hypertensive patients

AIMS

The CYBA C242T polymorphism has been associated with cardiovascular phenotypes such as hypertension and atherosclerosis, but available data are conflicting. This report investigated the impact of this variant on hypertension and metabolic determinants of cardiovascular risk in a large Brazilian sample.

METHODS

We cross-sectionally evaluated 1856 subjects (826 normotensive subjects and 1030 hypertensive patients) by clinical history, anthropometry, laboratory analysis and genotyping of the CYBA C242T polymorphism.

RESULTS

Genotype frequencies in the whole population were consistent with the Hardy-Weinberg equilibrium and genotype distributions were not different between hypertensive and normotensive subjects. Hypertensive patients with the CC genotype presented lower fasting plasma glucose levels (5.9 ± 0.1 vs. 6.2 ± 0.1 mmol/l, P = 0.020) and waist circumference (94.5 ± 0.6 vs. 96.3 ± 0.6 cm, P = 0.028) than CT + TT ones. Similarly, the prevalence of diabetes mellitus and obesity was also lower in hypertensive patients carrying the CC genotype (16% vs. 21%, P = 0.041; 36% vs. 43%, P = 0.029, respectively). In addition, multiple and logistic regression analysis demonstrated that the CYBA C242T polymorphism was associated with glucose levels, waist circumference, obesity and diabetes mellitus in hypertensive patients independently of potential confounders. Conversely, in normotensive subjects, no significant difference in studied variables was detected between the genotype groups.

CONCLUSIONS

These data suggest that the T allele of the CYBA C242T polymorphism may be used as a marker for adverse metabolic features in Brazilian subjects with systemic hypertension.

Hip circumference is associated with high density lipoprotein cholesterol response following statin therapy in hypertensive subjects

AIM

This report investigated the relationship between anthropometric measurements of body fat distribution and lipid response to statins in hypercholesterolemic hypertensive patients.

METHODS

We prospectively examined 129 subjects who used either simvastatin 20 mg/day (no.=83) or atorvastatin 10 mg/day (no.=46) for 3 months. Anthropometry included evaluation of body mass index, waist and hip circumferences, and waist-to-hip-ratio.

RESULTS

Significant decreases in LDL (p<0.001), total cholesterol (p<0.001), and triglycerides (p=0.04) levels were detected after 3 months of therapy in the whole sample. At baseline, only an inverse correlation between waist circumference and HDLcholesterol levels was detected (r=-0.18; p=0.04). Conversely, a direct relationship between hip circumference and HDLcholesterol response to statins was found in the whole sample (r=0.24; p=0.006), while no other anthropometric measurement displayed significant correlation with lipid changes. The association between HDL-cholesterol response and hip circumference was further confirmed by stepwise regression analysis adjusted for baseline HDL-cholesterol levels, metabolic syndrome, body mass index, and waist circumference.

CONCLUSIONS

Hip circumference, a surrogate marker of peripheral adiposity, is associated with HDL-cholesterol changes following statin therapy in hypertensive patients.

The effect of gluteus medius training on hip kinematics in a runner with iliotibial band syndrome

Iliotibial  band  syndrome  (ITBS)  is  a  common  clinical  presentation in  runners.  There  are  several  hypotheses  to  explain  this  condition  including  faulty  control of the hip joint in the frontal plane during the stance phase of running. It is postulated that improving activity in the gluteus medius muscle may assist in produc-ing  more  appropriate  stabilization and  therefore  reduce  the  stress  on  the  Iliotibial band  (ITB).  This  single  case  study  provides  an  interesting  clinical  scenario  where a single-subject with ITBS was measured for hip kinematics during running, before and after a trial period of classic gluteus medius exercises. The biomechanical data show an initial (pre-intervention) increase in adduction position during the stance phase of running on the affected side (in contrast to the unaffected side). This was measured using a Moven motion analysis suit. After the trial intervention period, the relative position of the affected hip had reduced in adduction at both heel strike and at 30° knee flexion. This study provides support  for the theory that hip control in the frontal plane may be a contributing factor in ITBS. Clinicians are encouraged to monitor hip control as well as ITBS symptoms when they utilise this gluteus medius protocol. Further research to establish whether change in pelvic control results in decrease in ITBS symptoms is warranted.

The potential and limitations of DOV 216,303 as a triple reuptake inhibitor for the treatment of major depression: a microdialysis study in olfactory bulbectomized rats

DOV 216,303 belongs to a new class of antidepressants, the triple reuptake inhibitors (TRIs), that blocks serotonin, norepinephrine and dopamine transporters and thereby increases extracellular brain monoamine concentrations. The aim of the present study was to measure extracellular monoamine concentrations both in the prefrontal cortex (PFC) and dorsal hippocampus (DH) after chronic administration of DOV 216,303 in the OBX animal model of depression and to compare the effects with acute drug treatment. OBX animals showed lower dopamine levels in PFC upon acute administration of DOV 216,303 than sham animals for up to five weeks after surgery. No such changes were observed in the DH. Unexpectedly, a DOV 216,303 challenge in chronic DOV 216,303 treated sham animals resulted in a blunted dopamine response in the PFC compared to the same challenge in vehicle treated animals. This blunted response probably reflects pharmacokinetic adaptations and/or pharmacodynamic changes, since brain and plasma concentrations of DOV 216,303 were significantly lower after chronic administration compared to acute administration. Surprisingly, and in contrast what we have reported earlier, chronic DOV 216,303 treatment was unable to normalize the hyperactivity of the OBX animals. Interestingly, by measuring the drug plasma and brain levels, it was demonstrated that at the time of behavioral testing (24 h after last drug treatment) DOV 216,303 was not present anymore in either plasma or brain. This seems to indicate that this putative antidepressant drug has no lasting antidepressant-like behavioral effects in the absence of the drug in the brain.

Localization and functional characterization of the human NKCC2 isoforms

AIM

Salt reabsorption across the apical membrane of cells in the thick ascending limb (TAL) of Henle is primarily mediated by the bumetanide-sensitive Na(+)/K(+)/2Cl(-) cotransporter NKCC2. Three full-length splice variants of NKCC2 (NKCC2B, NKCC2A and NKCC2F) have been described. The NKCC2 isoforms have specific localizations and transport characteristics, as assessed for rabbit, rat and mouse. In the present study, we aimed to address the localization and transport characteristics of the human NKCC2 isoforms.

METHODS

RT-PCR, in situ hybridization and uptake studies in Xenopus oocytes were performed to characterize human NKCC2 isoforms.

RESULTS

All three classical NKCC2 isoforms were detected in the human kidney; in addition, we found splice variants with tandem duplicates of the variable exon 4. Contrary to rodents, in which NKCC2F is the most abundant NKCC2 isoform, NKCC2A was the dominant isoform in humans; similarly, isoform-specific in situ hybridization showed high expression levels of human NKCC2A along the TAL. Compared to NKCC2B and NKCC2F, human NKCC2A had the lowest Cl(-) affinity as determined by (86)Rb(+) uptake studies in oocytes. All NKCC2 isoforms were more efficiently inhibited by bumetanide than by furosemide. A sequence analysis of the amino acids encoded by exon 4 variants revealed high similarities between human and rodent NKCC2 isoforms, suggesting that differences in ion transport characteristics between species may be related to sequence variations outside the highly conserved sequence encoded by exon 4.

CONCLUSION

The human NKCC2 is an example of how differential splicing forms the basis for a diversification of transporter protein function.

AMDIS Case Conference: Intrusive Medication Safety Alerts

Clinical decision support that provides enhanced patient safety at the point of care frequently encounters significant pushback from clinicians who find the process intrusive or time-consuming. We present a hypothetical medical center's dilemma about its allergy alerting system and discuss similar problems faced by real hospitals. We then share some lessons learned and best practices for institutions who wish to implement these tools themselves.

Cancer Immunoediting: Immunologic Control and Sculpting of Cancer

Cancer Immunoediting is the process by which the immune system controls and shapes cancer. We originally envisaged that cancer immunoediting would occur in three phases: Elimination (also known as cancer immunosurveillance, the host protective phase of the process), Equilibrium (the phase in which tumor cells that survive immune elimination remain under immunologic growth control resulting in a state of functional tumor dormancy) and Escape (the phase where clinically apparent tumors emerge because immune sculpting of the tumor cells has produced variants that display either reduced immunogenicity or enhanced immunosuppressive activity). Strong experimental data has now been obtained using mouse models of cancer to demonstrate the existence of each phase of the cancer immunoediting process and compelling clinical data suggests that a similar process may also occur during the evolution of certain types of human cancer. Our efforts now focus on elucidating the molecular and cellular mechanisms that underlie each phase of cancer immunoediting and identifying the critical checkpoints that regulate progression from one phase of the process to the next. This approach has led to the discovery of a new mouse cancer model that shows remarkable developmental, molecular and functional similarity to human estrogen receptor alpha positive (ERα+) luminal breast cancer. We have found that the cancers in our mice arise as a result of dysfunctional JAK-STAT pathway signaling and, interestingly, this observation has led to the discovery of a heretofore-unrecognized similar phenotype in a subset of human ERα+ luminal breast cancers. The therapeutic implications of our work will be discussed.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr BS3-1.

Mammary Tumors in STAT1-Deficient Mice Recapitulate Characteristics of Human Luminal Breast Cancers

Human breast cancer of the luminal subtype represents approximately 70% of all newly diagnosed breast cancers. This particular subtype of tumors are estrogen receptor α (ERα)-positive and/or progesterone receptor (PR)-positive. However, 50% of these patients do not derive benefit from endocrine therapy. One obstacle in the study of hormone receptor-positive breast cancer is that there is currently a deficit in murine models that can fully recapitulate the biology of this highly prevalent breast cancer subtype. Here we show that mice lacking the transcription factor signal transducers and activators of transcription 1 (STAT1) spontaneously developed mammary gland adenocarcinomas that showed remarkable similarities to human luminal breast cancer at histopathological, biological and molecular levels. More than 90% of the tumor cells in both early and advanced lesions were ERα+ and/or PR+. STAT1-/- mammary tumor cells failed to grow in ovariectomized mice, demonstrating that these tumors are addicted to ovarian hormones for proliferation. Supplementing with exogenous estrogen was sufficient to rescue tumor growth in ovariectomized mice. STAT1 functions, at least in part, as an intrinsic tumor suppressor since reconstitution of STAT1 expression in STAT1-/- mammary tumor cells induced spontaneous apoptosis. Induction of cell death required the critical tyrosine residue at position 701, suggesting that the transcriptional function of STAT1 is involved in tumor suppression.In contrast to the anti-oncogenic effect of STAT1, STAT3 was constitutively phosphorylated by JAK2 in the STAT1-/- mammary tumor cells. Inhibition of JAK2 or STAT3 activation resulted in tumor cell death, indicating that STAT3 promotes tumor cell survival. Gene expression profiles of the STAT1-/- mammary tumors showed significant overlaps with that of the human luminal breast cancers, strongly supporting that the STAT1-/- mammary tumors recapitulate the molecular signatures of human luminal breast cancers. Consistent with the results that STAT1 can act as an intrinsic tumor suppressor, approximately 10% of the human ERα+ breast cancer cases exhibit either undetectable or very low level of STAT1 in the mammary epithelial compartment. This study uncovers a unique role of STAT1 in suppressing mammary gland tumorigenesis. Importantly, this physiologically relevant model of human luminal breast cancer will provide an exceptional tool for the development and evaluation of novel therapeutics.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 65.

The neurotensin agonist NT69L improves sensorimotor gating deficits in rats induced by a glutamatergic antagonist, but not by dopaminergic agonists

An imbalance between different neurotransmitter systems is involved in the pathophysiological processes underlying schizophrenia. Since the neurotensin (NT) system modulates the activity of several of these neurotransmitters, drugs acting upon the NT system may act as novel antipsychotic drugs. This hypothesis is supported by studies with NT in animal models. For example, intracranial injection of NT improves sensorimotor gating in rats [Feifel D, Minor KL, Dulawa S, Swerdlow NR. The effects of intra-accumbens neurotensin on sensorimotor gating. Brain Research 1997;760:80-4]. NT-mimetics, such as NT69L, have been developed which are more resistant to enzymatic degradation than the native NT peptide. In the present study, the potential antipsychotic properties of NT69L were evaluated in a rat pre-pulse inhibition (PPI) paradigm. PPI is a measure of sensorimotor gating where a weak auditory stimulus, or pre-pulse, inhibits the startle response to a strong stimulus, or pulse. Schizophrenic patients exhibit deficits in their PPI response. This condition can be mimicked in rats with psychotomimetic drugs and the resulting PPI deficit is reversed by antipsychotic drugs. NT69L (0.1-10mg/kg i.p.) reversed disruptions of the PPI response induced by the NMDA antagonist dizocilpine (0.1mg/kg s.c.) for at least 1-h post-injection, but did not reverse disruptions induced by the dopaminergic agonists apomorphine and d-amphetamine (0.5 and 5mg/kg s.c., respectively). These results confirm that NT69L possesses antipsychotic-like activity and therefore could be beneficial in the treatment of schizophrenia.

European biliary atresia registries: summary of a symposium

Biliary atresia (BA) is a rare but potentially devastating disease. The European Biliary Atresia Registry (EBAR) was set up to improve data collection and to develop a pan-national and interdisciplinary strategy to improve clinical outcomes. From 2001 to 2005, 100 centers from 22 countries registered with EBAR via its website (www.biliary-atresia.com). In June 2006, the first meeting was held to evaluate results and launch further initiatives. During a 5-year period, 60 centers from 19 European countries and Israel sent completed registration forms for a total of 514 BA patients. Assuming the estimated incidence of BA in Europe is 1:18,000 live births, 35% of the expected 1488 patients from all EBAR participating countries were captured, suggesting that reporting arrangements need improvement. At the meeting, the cumulative evaluation of 928 BA patients including patients from other registries with variable follow-up revealed an overall survival of 78% (range from 41% to 92%), of whom 342 patients (37%) have had liver transplants. Survival with native liver ranged from 14% to 75%. There was a marked variance in reported management and outcome by country (e.g., referral patterns, timing of surgery, centralization of surgery). In conclusion, EBAR represents the first attempt at an overall evaluation of the outcome of BA from a pan-European perspective. The natural history and outcome of biliary atresia is of considerable relevance to a European population. It is essential that there is further support for a pan-European registry with coordination of clinical standards, further participation of parent support groups, and implementation of online data entry and multidisciplinary clinical and basic research projects.

Improving memory: a role for phosphodiesterases

During the last decennia, our understanding of the neurobiological processes underlying learning and memory has continuously improved, leading to the identification of targets for the development of memory-enhancing drugs. Here we review a class of drugs which has more recently been identified: the phosphodiesterase (PDE) inhibitors. An overview is given of the different PDEs that are known and we focus on three PDEs which have been identified as possible relevant targets for memory improvement: PDE2, PDE4 and PDE5. PDEs differ in the substrate, i.e. cyclic adenosine monophosphate (cAMP) and/or cyclic guanosine monophosphate (cGMP), being hydrolyzed. Since these cyclic nucleotides have been suggested to play distinct roles in processes of memory, selective PDE inhibitors preventing the breakdown of cAMP and/or cGMP could improve memory. The present data suggest that PDE4 (cAMP) is involved in acquisition processes, although a possible role in late consolidation processes cannot be excluded. PDE5 (cGMP) is involved in early consolidation processes. Since PDE2 inhibition affects both cAMP and cGMP, PDE2 inhibitors may improve both memory processes. The field of PDEs is highly dynamic and new isoforms of PDEs are still being described. This may lead to the discovery and development of new memory enhancing drugs that selectively inhibit such isoforms. Such drugs may exert their effects only in specific brain areas and hence possess an improved side effect profile.

Expression of cardiomyocytic markers on adipose tissue-derived cells in a murine model of acute myocardial injury

Animal and early clinical studies have provided evidence suggesting that intracoronary administration of autologous bone marrow-derived cells results in improved outcome following myocardial infarction. Animal studies with cultured marrow stromal cells (MSC) have provided similar data. Cells with properties that are similar to MSC have been identified in adipose tissue. Other groups have demonstrated in vivo differentiation of adipose tissue-derived cells (ADC) into cells exhibiting biochemical and functional markers of cardiac myocytes, including spontaneous beating. Based on these observations, the objective of the present study was to determine whether ADC might undergo similar differentiation in vivo in the context of myocardial injury.ADC were isolated from subcutaneous adipose tissue of Rosa26 mice (which express the beta-galactosidase transgene in almost every tissue) and injected into the intraventricular chamber of B6129S recipient mice immediately following induction of myocardial cryoinjury. Groups of recipients were euthanized at 24 hours, 7 and 14 days post surgery and examined for the presence of donor-derived cells within the heart.Beta-gal positive cells were identified in the infarcts of ADC-treated animals. No staining was observed in uninjured myocardium or in infarcts of control animals. Immunohistochemical analysis revealed co-expression of beta-gal with Myosin Heavy Chain, Nkx2.5 and with Troponin I. Co-expression of beta-galactosidase with Connexin 43, CD31, von Willebrand factor, MyoD or CD45 was not detected.Thus, these data indicate that adipose tissue contains a population of cells that has the ability to engraft injured myocardium and that this engraftment is associated with expression of cardiomyocytic markers by donor-derived cells.

Ca2+ signaling, intracellular pH and cell volume in cell proliferation

Mitogens control progression through the cell cycle in non-transformed cells by complex cascades of intracellular messengers, such as Ca2+ and protons, and by cell volume changes. Intracellular Ca2+ and proton concentrations are critical for linking external stimuli to proliferation, motility, apoptosis and differentiation. This review summarizes the role in cell proliferation of calcium release from intracellular stores and the Ca2+ entry through plasma membrane Ca2+ channels. In addition, the impact of intracellular pH and cell volume on cell proliferation is discussed.

5-HT1A receptors are differentially involved in the anxiolytic- and antidepressant-like effects of 8-OH-DPAT and fluoxetine in the rat

Fluoxetine, a selective serotonin reuptake inhibitor, shows moderate efficacy and potency in the rat forced swimming depression test and the shock-induced ultrasonic vocalization anxiety test, whereas the 5-HT(1A) receptor agonist (+/-)-8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT) is highly efficient and potent in both models. Whereas the 5-HT(1A) receptor antagonist WAY 100,635 abolishes the effect of 8-OH-DPAT in both models, it only attenuates the antidepressant-like effect of fluoxetine. Pretreatment with the 5-HT-depleting agent parachlorophenylalanine attenuates the antidepressant-like effect of fluoxetine, but not that of 8-OH-DPAT. This suggests that the antidepressant-like effect of fluoxetine and 8-OH-DPAT results from indirect (via increased synaptic availability of 5-HT) and direct stimulation of postsynaptic 5-HT(1A) receptors, respectively; whereas the anxiolytic-like effect of fluoxetine is not mediated by 5-HT(1A) receptors. The data support the hypothesis that the antidepressant- and anxiolytic-like effect of 8-OH-DPAT is predominantly mediated by post- and presynaptic 5-HT(1A) receptors, respectively, and that 5-HT(1A) receptors are only partially involved in the antidepressant-like effect of fluoxetine.