Information In Clinical Settings Research Articles

The DTI Challenge: Toward Standardized Evaluation of Diffusion Tensor Imaging Tractography for Neurosurgery.

Diffusion tensor imaging (DTI) tractography reconstruction of white matter pathways can help guide brain tumor resection. However, DTI tracts are complex mathematical objects and the validity of tractography-derived information in clinical settings has yet to be fully established. To address this issue, we initiated the DTI Challenge, an international working group of clinicians and scientists whose goal was to provide standardized evaluation of tractography methods for neurosurgery. The purpose of this empirical study was to evaluate different tractography techniques in the first DTI Challenge workshop. Eight international teams from leading institutions reconstructed the pyramidal tract in four neurosurgical cases presenting with a glioma near the motor cortex. Tractography methods included deterministic, probabilistic, filtered, and global approaches. Standardized evaluation of the tracts consisted in the qualitative review of the pyramidal pathways by a panel of neurosurgeons and DTI experts and the quantitative evaluation of the degree of agreement among methods. The evaluation of tractography reconstructions showed a great interalgorithm variability. Although most methods found projections of the pyramidal tract from the medial portion of the motor strip, only a few algorithms could trace the lateral projections from the hand, face, and tongue area. In addition, the structure of disagreement among methods was similar across hemispheres despite the anatomical distortions caused by pathological tissues. The DTI Challenge provides a benchmark for the standardized evaluation of tractography methods on neurosurgical data. This study suggests that there are still limitations to the clinical use of tractography for neurosurgical decision making.

Abstract 3350: Plucked hair as a biomarker platform for monitoring transcriptional consequences of clinical exposure to antagonism of the HDM2/P53 interaction in tumors.

Abstract The ability to assess and monitor target engagement is crucial for informing early drug development decisions. High vascularisation of the hair follicle, frequent epithelial origin of tumors, and high degree of congruence of expression in hair of pathways dysregulated in cancers, makes the cellular bulb on plucked human scalp hair an excellent surrogate tissue for non-invasive monitoring of PD effects in clinical trials. Disruption of the p53-HDM2 interaction with small molecules has demonstrated single agent anti-tumor activity in preclinical models and represents an attractive treatment strategy in oncology. Development of a peripheral tissue based gene expression signature of inhibition of the p53-HDM2 interaction could facilitate the early development of these compounds. To develop a peripheral PD biomarker of antagonism of this interaction, we used two selective p53-HDM2 antagonists, Nutlin-3 and Sanofi's SAR405838 and applied our plucked hair biomarker platform to develop a gene expression signature indicative of compound exposure. SAR405838 displays potent activity in vitro and in vivo against p53 WT cell lines / xenograft models, but not in the p53 mutant context. Three hairs from each of four healthy donors were exposed to either SAR405838 or Nutlin-3 over a range of compound concentrations for 6hr or 24hr in our proprietary ex vivo cultures. We extracted RNA from the cellular bulb of individual hairs and assessed the transcriptome by microarray analysis. Biological enrichment analysis of genes differentially expressed revealed strong correlation to activated P53 signaling pathways. Further analysis revealed a core set of congruent genes as candidate PD biomarkers of p53-HDM2 antagonism, one of which was MIC-1, a secreted plasma protein that demonstrates a strong PK/PD relationship in patients treated with p53-MDM2 antagonists in Phase 1 trials. In ex vivo plucked hair, we have demonstrated biologically relevant differential expression of a panel of transcriptional markers exhibiting common response to Nutlin-3 and SAR405838. These reflect compound mechanism of action, and can provide further evidence of target engagement in addition to plasma MIC-1 levels. While the temporal and kinetic relationship between gene expression changes, toxicity, and clinical efficacy remains to be determined, the genes identified in this study may be used to provide further MOA information in clinical settings to monitor PD responses in plucked scalp hair obtained from patients exposed to SAR405838. Citation Format: Gino Miele, Elliot Harrison, Tim Mefo, Jo Read, Lydia Meyer Turkson, Alan Murdoch, Michael Teufel, Laurent Debussche, Donald Bergstrom, James Watters. Plucked hair as a biomarker platform for monitoring transcriptional consequences of clinical exposure to antagonism of the HDM2/P53 interaction in tumors. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 3350. doi:10.1158/1538-7445.AM2013-3350

Why is clinical information not reused?

Reuse of clinical information plays a key role in the vision of a health sector with comprehensive semantic and pragmatic interoperability. Several papers have dealt with the secondary reuse of information, e.g. for statistics or research, while the primary reuse - clinical information reused in a clinical setting - has received less attention. On the basis of a qualitative literature review, this paper creates a categorised overview of the different causes to refrain from reuse of clinical information in clinical settings. The categorisation contributes to a greater understanding of failing reuse of clinical information in clinical settings, and it can probably be used in designing, evaluating and optimising clinical information systems. Further, it is speculated that the categorisation can be used in the process of identifying the concepts that constitute the context of clinical information.

Clinical Considerations of Heritable Factors in Common Heart Failure

Heart failure is a common condition responsible for at least 290 000 deaths each year in the United States alone.1 A small minority of heart failure cases are attributed to Mendelian or familial cardiomyopathies. The majority of systolic heart failure cases are not familial but represent the end result of 1 or many conditions that primarily injure the myocardium sufficiently to diminish cardiac output in the absence of compensatory mechanisms. Paradoxically, because they also injure the myocardium, it is the chronic actions of the compensatory mechanisms that in many instances contribute to the progression from simple cardiac injury to dilated cardiomyopathy and overt heart failure. Thus, the epidemiology of common heart failure appears to be just as sporadic as its major antecedent conditions (atherosclerosis, diabetes, hypertension, and viral myocarditis). Familial trends in preclinical cardiac remodeling2 and risk of developing heart failure3 reveal an important role for genetic modifiers in addition to clinical and environmental factors. Candidate gene studies performed over the past 10 years have identified a few polymorphic gene variants that modify risk or progression of common heart failure.4 Whole-genome sequencing will lead to the discovery of other genetic modifiers that were not candidates.5 The imminent availability of individual whole-genome sequences at a cost competitive with available genetic tests for familial cardiomyopathy will no doubt further expand the list of putative genetic heart failure modifiers. Heart failure risk alleles along with traditional clinical factors will need to be considered by clinical cardiologists in their design of optimal disease surveillance and prevention programs and in individually tailoring heart failure management. The use of individual genetic make-up is likely to have the earliest and greatest impact on managing patients with heart failure by tailoring available pharmacotherapeutics to optimize patient response and minimize adverse effects (ie, the …

Technology, work, and information flows: Lessons from the implementation of a wireless alert pager system

The combination of collaborative work practices and information technology affect the flow of information in clinical settings. The introduction of a new technology into these settings can change not only established work practices but also the information flows. In this paper, we examine the introduction of a wireless alerts pager in a surgical intensive care unit (SICU). Through a qualitative study, we analyze the effects that this new information tool had on both the work practices in the SICU and the information flow in the unit. We describe four challenges that SICU staff members faced with respect to the alerts pagers. We found that the pager provided new routes of information to SICU staff but in doing so disrupted existing work practices and information flows.

Integrating Abilities and Interests in Career Choice: Maximal versus Typical Assessment

The present article focuses on ways in which structural information from the ability and interest domains can be usefully integrated to inform career development and choice processes as well as allied research. Examining the structural models in these two domains, in addition to the distinction between maximal and typical assessment, the authors suggest that self-assessments of ability/self-efficacy have greater utility than assessments of maximal ability for informing career exploration and choice. Given this, they note several ways that self-ratings of ability can be integrated with interest information in clinical settings. In the second section, they focus on the definition of the general factor in vocational interest data. The authors hypothesize that this factor can be interpreted as interest flexibility and is particularly salient as a moderator in the person-environment fit-career outcome relation. They then propose a number of testable hypotheses relevant to this relation.

Family-centered approaches to understanding and preventing coronary heart disease

Family history represents the contributions and interactions of unique genomic and ecologic factors that affect the metabolic profile and life course of a family and its members. It is well known that a family history of coronary heart disease (CHD) is a significant predictor of an individual’s risk for CHD even after adjusting for an individual’s own established risk factors, such as hypertension, smoking, and abnormal lipoprotein levels. The explanation for the observed familial disease aggregation is not well understood except for the general knowledge that genetic and environmental factors predisposing to CHD also aggregate in families. Given the multifactorial nature of an individual’s risk, it can be argued that an individual’s familial risk of disease may, in fact, be a better indicator of the many complex interactions among predisposing genetic and environmental factors than can be captured by an individual’s own risk factors. Issues of how to assess, quantitate, and apply family history information in clinical settings still need to be resolved. Some clinical risk indicators, such as the National Cholesterol Education Program III guidelines, take into account family history, while others, such as the Framingham Risk Score, do not. Moreover, several family-centered intervention studies have demonstrated the particular advantages of focusing on families rather than just individuals. Although there has been tremendous progress in primary prevention of CHD over the last 20 years, substantial advancements may still be achieved by focusing on the family as its own unit of inference and as a specific target for disease prevention.

The Multidimensional Observation Scale for Elderly Subjects (MOSES): studies in adults with intellectual disability

This report describes the results of five studies aimed at evaluating the usefulness, reliability, and validity of the Multidimensional Observation Scale for Elderly Subjects (MOSES) in the assessment of change in ageing persons with intellectual disability. Three hundred and thirty-six individuals with an average age of 49.8 years, including an equal number of men and women, were participants in one or more of the five studies. There were 220 participants with Down syndrome, 81 persons without Down syndrome with intellectual disability, and 35 persons from the general ageing population who were clinically diagnosed with Alzheimer's disease using NINCD/ADRDA criteria. Persons with Down syndrome 40 years of age and older could be distinguished from their younger peers with Down syndrome by statistically significant poorer scores on the MOSES, with those 50 years of age and older showing the worst scores. Comparisons of adults with intellectual disability diagnosed with dementia of the Alzheimer type (DAT), using DSM-IV criteria, with or without Down syndrome, as well as comparisons of patients with clinically diagnosed depression, provided evidence that subtests of the MOSES were sensitive to DAT but less so to depression. These clinical groups also showed significantly poorer scores on the MOSES when compared with those of the normative sample. It was concluded that the MOSES is a behavioural observation scale that can provide useful information in clinical settings as well as in research.

The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. (St. Gemma's Hospice, Leeds, United Kingdom) Pain. 2001;92:147–157.

This study described the development and validation of a novel tool for identifying patients in whom neuropathic mechanisms dominate their pain experience. The Leeds assessment of neuropathic symptoms and signs (LANSS) Pain Scale is based on analysis of sensory description and bedside examination of sensory dysfunction, and provides immediate information in clinical settings. It was developed in 2 populations of chronic pain patients. In the first, the use of sensory descriptors and questions were compared in patients with nociceptive and neuropathic pain, combined with an assessment of sensory function. This data was used to derive a 7‐item pain scale, consisting of grouped sensory description and sensory examination with a simple scoring system. The LANSS Pain Scale was validated in a second group of patients by assessing discriminant ability, internal consistency, and agreement by independent raters. Clinical and research applications of the LANSS Pain Scale are discussed.

The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs

This study describes the development and validation of a novel tool for identifying patients in whom neuropathic mechanisms dominate their pain experience. The Leeds assessment of neuropathic symptoms and signs (LANSS) Pain Scale is based on analysis of sensory description and bedside examination of sensory dysfunction, and provides immediate information in clinical settings. It was developed in two populations of chronic pain patients. In the first ( n=60), the use of sensory descriptors and questions were compared in patients with nociceptive and neuropathic pain, combined with an assessment of sensory function. This data was used to derive a seven item pain scale, consisting of grouped sensory description and sensory examination with a simple scoring system. The LANSS Pain Scale was validated in a second group of patients ( n=40) by assessing discriminant ability, internal consistency and agreement by independent raters. Clinical and research applications of the LANSS Pain Scale are discussed.

Improving access to computer-based library and drug information services in patient-care areas

A project to increase access to drug and biomedical information through electronic linkage of drug information and library services to three patient-care areas is described. In February 1987, microcomputer work stations were installed in the Bexar County Hospital District's hospital emergency department, medical residents' office, and ambulatory-care clinic, as well as in The University of Texas Health Science Center's library reference area and drug information service office. Drug information was available on compact disk through the Micromedex Computerized Clinical Information System (CCIS) database, which includes DRUGDEX, POISINDEX, EMERGINDEX, and IDENTIDEX. Each work station was also connected to the library's computer via modem, allowing access to the Library Information System, books, journals, audiovisual materials, miniMEDLINE, and an electronic mail system. During the six-month project, the system was used 5487 times by 702 people. The system was successful in providing drug and other information in clinical settings and in introducing clinical staff members to new information technology. To increase access to the system after the project ended, the CD-ROM version was discontinued, and the distributed tape version of CCIS for VAX computers was added to the library's online information system, making drug information more available throughout the campus and teaching hospitals. In 1988-89 an average of 200 people accessed the tape version of CCIS each month. Although it is difficult to replace the convenience of an onsite library, at least some drug and biomedical information needs in the clinical setting can be met through computer networking.

The communication process in clinical settings

The communication of information in clinical settings is fraught with problems despite avowed common aims of practitioners and patients. Some reasons for the problematic nature of clinical communication are incongruent frames of reference about what information ought to be shared, sociolinguistic differences and social distance between practitioners and patients. Communication between doctors and nurses is also problematic, largely due to differences in ideology between the professions about what ought to be communicated to patients about their illness and who is ratified to give such information. Recent social changes, such as the Patient Bill of Rights and informed consent which assure access to information, and new conceptualizations of the nurse's role, warrant continued study of the communication process especially in regard to what constitutes appropriate and acceptable information about a patient's illness and who ought to give such information to patients. The purpose of this paper is to outline characteristics of communication in clinical settings and to provide a literature review of patient and practitioner interaction studies in order to reflect on why information exchange is problematic in clinical settings. A framework for presentation of the problems employs principles from interaction and role theory to investigate clinical communication from three viewpoints: (1) the level of shared knowledge between participants; (2) the effect of status, role and ideology on transactions; and (3) the regulation of communication imposed by features of the institution.

Density patterns in the normal lung as determined by computed tomography.

Lung density patterns in a group of randomly selected, normal individuals were determined by computed tomography, using two methods: one measuring the density of the peripheral lung (parenchyma), and the other determining the density of the whole lung field. The effects of body position and respiratory phase, as well as patient age were assessed. The potential use for this information in clinical settings and in physiological investigation is suggested.