Factors facilitating the implementation of a clinical decision support system in primary care practices: a fuzzy set qualitative comparative analysis

BACKGROUND

Understanding how to implement innovations in primary care practices is key to improve primary health care. Aiming to contribute to this understanding, we investigate the implementation of a clinical decision support system (CDSS) as part of the innovation fund project AdAM (01NVF16006). Originating from complexity theory, the practice change and development model (PCD) proposes several interdependent factors that enable organizational-level change and thus accounts for the complex settings of primary care practices. Leveraging the PCD, we seek to answer the following research questions: Which combinations of internal and external factors based on the PCD contribute to successful implementation in primary care practices? Given these results, how can implementation in the primary care setting be improved?

METHODS

We analyzed the joint contributions of internal and external factors on implementation success using qualitative comparative analysis (QCA). QCA is a set-theoretic approach that allows to identify configurations of multiple factors that lead to one outcome (here: successful implementation of a CDSS in primary care practices). Using survey data, we conducted our analysis based on a sample of 224 primary care practices.

RESULTS

We identified two configurations of internal and external factors that likewise enable successful implementation. The first configuration enables implementation based on a combination of Strong Inside Motivation, High Capability for Development, and Strong Outside Motivation; the second configuration based on a combination of Strong Inside Motivators, Many Options for Development and the absence of High Capability for Development.

CONCLUSION

In line with the PCD, our results demonstrate the importance of the combination of internal and external factors for implementation outcomes. Moreover, the two identified configurations show that different ways exist to achieve successful implementation in primary care practices.

TRIAL REGISTRATION

AdAM was registered on ClinicalTrials.gov ( NCT03430336 ) on February 6, 2018.

Conservative treatment of gastric perforation after microwave ablation of a hepatocellular carcinoma: Case report

RATIONALE

Microwave ablation (MWA) has been proven to be an efficient and safe method for local tumor control of liver tumors. Reported complications are rare, but include liver abscess, hematoma, pleural effusion, and occasional thermal injury of the adjacent colon. Intestinal perforation usually requires immediate surgical treatment to prevent generalized peritonitis and sepsis.

PATIENT CONCERNS AND DIAGNOSIS

Herein, we describe a case of gastric perforation following percutaneous MWA for hepatocellular carcinoma as a bridging therapy prior to liver transplantation.

INTERVENTIONS

Due to the clinical condition of the patient, conservative treatment was considered sufficient. Nine months after MWA, successful liver transplantation followed. Intraoperative findings revealed a scar in the gastric wall with tight adhesions to the liver, requiring adhesiolysis and subsequent suturing. Postoperative recovery was uneventful.

OUTCOME

At present, the patient is doing well. No further gastrointestinal events occurred.

LESSON

To our knowledge, this is the first report of such a complication occurring after MWA. Moreover, in this case, the gastric perforation could be treated conservatively.

Antegrade papillotome navigation as a novel next-line approach for internalization of percutaneous transhepatic biliary drainage

There is an increasing rivalry between percutaneous transhepatic (PTBD) vs. endoscopic ultrasound-guided biliary drainage (EUS-BD) as rescue techniques after failed endoscopic retrograde cholangiography (ERC) access. While EUS-BD procedures hold a bright future, innovations in PTBD technique are still possible and clinically meaningful, at least so, under the a conceptual framework understanding PTBD as a bridging, anatomy-respecting technology for definitive biliary metal stenting. This, however, calls for successful PTBD internalization as a sine qua non. Against this background, here, I present a novel approach of PTBD internalization using a standard triple-lumen papillotome as a stiff catheter for probing and assisting in guidewire cannulation of the route to the duodenum. This is the first report on such re-purposed use of a papillotome, which may be instrumental in fine-tuning contrast media filling and crossing angulations within the biliary system. Taken together, innovative advancements and variations in PTBD technique, such as the presented "antegrade papillotome navigation", may rescue difficult PTBD internalization and, thus, potentially obviate the need for alternative approaches, including pure EUS-BD or even more complex hybrid PTBD-EUS procedures.

AAV5-miHTT gene therapy demonstrates suppression of mutant huntingtin aggregation and neuronal dysfunction in a rat model of Huntington's disease

Huntington’s disease (HD) is a fatal progressive neurodegenerative disorder caused by a mutation in the huntingtin (HTT) gene. To date, there is no treatment to halt or reverse the course of HD. Lowering of either total or only the mutant HTT expression is expected to have therapeutic benefit. This can be achieved by engineered micro (mi)RNAs targeting HTT transcripts and delivered by an adeno-associated viral (AAV) vector. We have previously showed a miHTT construct to induce total HTT knock-down in Hu128/21 HD mice, while miSNP50T and miSNP67T constructs induced allele-selective HTT knock-down in vitro. In the current preclinical study, the mechanistic efficacy and gene specificity of these selected constructs delivered by an AAV serotype 5 (AAV5) vector was addressed using an acute HD rat model. Our data demonstrated suppression of mutant HTT messenger RNA, which almost completely prevented mutant HTT aggregate formation, and ultimately resulted in suppression of DARPP-32-associated neuronal dysfunction. The AAV5-miHTT construct was found to be the most efficient, although AAV5-miSNP50T demonstrated the anticipated mutant HTT allele selectivity and no passenger strand expression. Ultimately, AAV5-delivered-miRNA-mediated HTT lowering did not cause activation of microglia or astrocytes suggesting no immune response to the AAV5 vector or therapeutic precursor sequences. These preclinical results suggest that using gene therapy to knock-down HTT may provide important therapeutic benefit for HD patients and raised no safety concerns, which supports our ongoing efforts for the development of an RNA interference-based gene therapy product for HD.

Multidisciplinary treatment of desmoid tumours in Gardner's syndrome due to a large interstitial deletion of chromosome 5q

BACKGROUND AND AIMS

Classic autosomal-dominant familial adenomatous polyposis (FAP) is clinically defined by the development of hundreds to thousands of colorectal adenomas beginning in childhood and adolescence. A variant of FAP characterized by polyposis in combination with osteomas or soft tissue tumours is called Gardner's syndrome. FAP is caused by germline inactivation of the APC (adenomatous polyposis coli) tumour-suppressor gene located on the long arm of chromosome 5 (5q21-5q22). Cytogenetically visible deletions of chromosome 5q encompassing APC have very rarely been reported. Here, we aimed to phenotypically and genetically characterize a patient with a heterozygous 5q deletion resulting in Gardner's syndrome.

METHODS AND RESULTS

A 26-year-old female patient with mild mental handicap and dysmorphic features due to a cytogenetically visible deletion on chromosome 5q (microscopically estimated region 5q14-5q23) presented at our tertiary referral centre because of mild adenomatous polyposis (<500 polyps). Twenty months after prophylactic proctocolectomy with definitive ileostomy, three rapidly growing desmoids were observed. Tumour-associated complications necessitated a multidisciplinary approach including medical treatment, surgery and radiation therapy. The characterization of the deletion by comparative genomic hybridization identified a large 5q deletion expanding over a 20-Mb region (5q21.3-5q23.3) including the APC gene.

CONCLUSION

Chromosome deletions must be suspected in patients presenting with FAP together with mental handicap and dysmorphic features. This case also impressively shows that FAP-associated desmoids need multimodal treatment taking into account the patient's individual symptoms, disease progression and tumour location.

Indication of reactor ν(e) disappearance in the Double Chooz experiment

The Double Chooz experiment presents an indication of reactor electron antineutrino disappearance consistent with neutrino oscillations. An observed-to-predicted ratio of events of 0.944±0.016(stat)±0.040(syst) was obtained in 101 days of running at the Chooz nuclear power plant in France, with two 4.25 GW(th) reactors. The results were obtained from a single 10 m(3) fiducial volume detector located 1050 m from the two reactor cores. The reactor antineutrino flux prediction used the Bugey4 flux measurement after correction for differences in core composition. The deficit can be interpreted as an indication of a nonzero value of the still unmeasured neutrino mixing parameter sin(2)2θ(13). Analyzing both the rate of the prompt positrons and their energy spectrum, we find sin(2)2θ(13)=0.086±0.041(stat)±0.030(syst), or, at 90% C.L., 0.017<sin(2)2θ(13)<0.16.

Severe hepatocellular dysfunction in obstetric cholestasis related to combined genetic variation in hepatobiliary transporters

Obstetric cholestasis (OC) is a cholestatic disorder with a prominent genetic background including variation in diverse hepatobiliary lipid transporters, such as ABCB4 (phospholipids) and ABCB11 (bile salts). Given a marked hepatocellular dysfunction in an OC patient indicated by > 40-fold rise in alanine aminotransferase activity and minor gamma-glutamyl transpeptidase increases, we performed genotyping of candidate gene variants associated with adult cholestatic phenotypes. Genetic analysis revealed the heterozygous ABCB4 mutation p.R590Q, the ABCB11 variant p.V444A and the lithogenic ABCG8 variant p.D19H. Aggregation of multiple hepatobiliary transporter variants is rare in OC, and may cooperate to negatively modulate hepatobiliary transport capacities.

Heterozygosity for the alpha1-antitrypsin Z allele may confer genetic risk of cholangiocarcinoma

BACKGROUND

Alpha1-antitrypsin (α1AT) deficiency caused by Z allele homozygosity represents a well-established risk factor for hepatocellular carcinoma. Previous studies have also implicated α1AT Z heterozygosity in cholangiocarcinogenesis.

AIM

To assess the 'common' Z and S alleles as well as the promoter variant rs8004738 for association with cholangiocarcinoma.

METHODS

We genotyped 182 Caucasian patients and 350 controls for rs28929474 (Z), rs17580 (S) and the variant rs8004738. Exploratory analyses were performed in relation to gender and cholangiocarcinoma localisation.

RESULTS

rs28929474 was significantly enriched in the cholangiocarcinoma group (4.1 vs. 1.7%; OR 2.46, 95% CI 1.14-5.32; Bonferroni corrected p(c) = 0.036), reinforced by Armitage trend testing (OR 2.53; p(c) = 0.032). The rs8004738 (promoter) minor allele tended to be overrepresented in Z heterozygotes (30.0 vs. 16.7%: P = 0.13). Exploratory data analyses suggested a high genetic risk for extrahepatic tumour localisation (OR 3.0; p(c) = 0.016) and potentially female Z allele carriers (OR 3.37; unadjusted P = 0.022, p(c) = 0.088).

CONCLUSIONS

These data point to a novel role of α1AT Z heterozygosity as a potential genetic susceptibility factor for cholangiocarcinoma formation and suggest a contribution of aberrant α1AT function in biliary carcinogenesis. However, given the overall low rs28929474 minor allele frequency, larger studies are warranted to confirm and extend our findings.

Genotypic interaction and gender specificity of common genetic variants in the p53/mdm2 network in Crohn's disease

BACKGROUND/AIMS

Defective p53-mediated apoptosis and cell cycle control have been implicated in the immunopathogenesis of Crohn's disease (CD). Since common functional variants of p53 (SNP72 G/C) and its key negative regulator mdm2 (SNP309 T/G) have been reported to affect cellular apoptotic and cell cycle arrest capacities, we assessed the effects of these variants on CD susceptibility and their relationship to NOD2/CARD15 as a well-established genetic CD risk factor.

METHODS

The variants SNP72 G/C and SNP309 T/G were genotyped in 149 European CD patients and 478 healthy controls. Subgroup analysis was performed in relation to NOD2/CARD15 status and to demographic/clinical characteristics.

RESULTS

The p53 SNP72 CC genotype tended to be less frequent in CD. This reached statistical significance only in the male cohort (0 vs. 7.3%; p = 0.037). Genotype and allele frequencies of both single-nucleotide polymorphisms (SNPs) were otherwise not significantly different. In the combined genotypic analysis, the genotype p53 SNP72 CC was significantly underrepresented in mdm2 SNP309 TT homozygotes (0 vs. 9.7%; p = 0.034). No association was observed between NOD2/CARD15 and the respective SNPs.

CONCLUSION

We report on a gender-specific protective effect of the low-apoptotic SNP72 CC genotype, and a gender-unrestricted genotypic interaction between SNP309 TT and SNP72 CC, which, for the first time, links sequence variation of the p53/mdm2 network to CD, independent of NOD2/CARD15.

Nutrient and suspended solid loads in the Laguna de Bay, Philippines

The Laguna de Bay is the largest lake in the Philippines and is situated 15 km southeast of the centre of Metropolitan Manila. The population of the capital region is growing out of proportion, especially in the watershed area of the lake. This development is endangering the resource Laguna de Bay due to the increasing discharge of nutrient and suspended solid loads from the drainage basin into the lake. During the EU-funded project "Laguna de Bay, Philippines: An Ecosystem Approach for Sustainable Management" a monitoring campaign on selected tributary rivers was conducted. Based on the results of this monitoring and an analysis of census data, the total annual loads were estimated at about 8000 t N, 2300 t P and 160,000 t TSS. The occurrence of the typhoon "Loleng" in the research area during the monitoring campaign made it possible to state that about 25% of the annual load is drained during such a weather situation.

Relationship between epidermal growth factor receptor (EGF-R) and various prognostic factors in human endometrial carcinoma

Eighty primary endometrial carcinomas were analyzed for the presence of epidermal growth factor receptors (EGF-R) by the use of a single point (1ng 125I-EGF) EGF-R assay. Fifty percent of the analyzed specimens were EGF-R positive (EGF-R(+)) with binding capacities > 1 fmol mg-1 and 15% bound > 7 fmol mg-1. The EGF-R status was correlated with different clinically relevant prognostic factors and the survival rates were analyzed. The correlations revealed no significant differences in the grade of tumor differentiation and in the depth of myometrial invasion. The advanced tumor stages III and IV and tumors with a squamous cell component in the histologic examination expressed EGF-R in a higher percentage. Between the EGF-R and the steroid receptor status existed a weak negative correlation. Estrogen receptor positive tumors were in 47% and progesterone receptor positive tumors in 45% EGF-R (+). The corresponding number for the receptor negative tumors were 57 and 65%. Life table analyses were performed with different cut-off limits for specific EGF binding ranging from > 1, > 3, > 5 and > 7 fmol mg-1. Dependent on the cut-off limits the analysis demonstrates a reduced survival probability for patients with EGF-R+ tumors. These differences were mainly found in the small group with a high number of EGF-R's (> 7 fmol). The analysis of tissue extracts for the presence of factors binding to the EGF-R revealed in some specimens high concentrations of EGF-like factors. By the use of TGFa (transforming growth factor alpha) immunohistochemistry we were able to demonstrate that the tumor cells produce TGFa, whereas the stroma is TGFa negative. We assume that the EGF-like factors consist mainly of TGFa.