A systematic quality assurance framework for the upgrade of radiation oncology information systems

In spite of its importance, no systematic and comprehensive quality assurance (QA) program for radiation oncology information systems (ROIS) to verify clinical and treatment data integrity and mitigate against data errors/corruption and/or data loss risks is available. Based on data organization, format and purpose, data in ROISs falls into five different categories: (1) the ROIS relational database and associated files; (2) the ROIS DICOM data stream; (3) treatment machine beam data and machine configuration data; (4) electronic medical record (EMR) documents; and (5) user-generated clinical and treatment reports from the ROIS. For each data category, this framework proposes a corresponding data QA strategy to very data integrity. This approach verified every bit of data in the ROIS, including billions of data records in the ROIS SQL database, tens of millions of ROIS database-associated files, tens of thousands of DICOM data files for a group of selected patients, almost half a million EMR documents, and tens of thousands of machine configuration files and beam data files. The framework has been validated through intentional modifications with test patient data. Despite the ‘big data’ nature of ROIS, the multiprocess and multithread nature of our QA tools enabled the whole ROIS data QA process to be completed within hours without clinical interruptions. The QA framework suggested in this study proved to be robust, efficient and comprehensive without labor-intensive manual checks and has been implemented for our routine ROIS QA and ROIS upgrades.     

A systems-theoretical framework for health and disease: inflammation and preconditioning from an abstract modeling point of view

Modern advances in molecular biology have produced enormous amounts of data characterizing physiological and disease states in cells and organisms. While bioinformatics has facilitated the organizing and mining of these data, it is the task of systems biology to merge the available information into dynamic, explanatory and predictive models. This article takes a step into this direction. It proposes a conceptual approach toward formalizing health and disease and illustrates it in the context of inflammation and preconditioning. Instead of defining health and disease states, the emphasis is on simplexes in a high-dimensional biomarker space. These simplexes are bounded by physiological constraints and permit the quantitative characterization of personalized health trajectories, health risk profiles that change with age, and the efficacy of different treatment options. The article mainly focuses on concepts but also briefly describes how the proposed concepts might be formulated rigorously within a mathematical framework.     

Predicting the Risk of Suicide by Analyzing the Text of Clinical Notes

We developed linguistics-driven prediction models to estimate the risk of suicide. These models were generated from unstructured clinical notes taken from a national sample of U.S. Veterans Administration (VA) medical records. We created three matched cohorts: veterans who committed suicide, veterans who used mental health services and did not commit suicide, and veterans who did not use mental health services and did not commit suicide during the observation period (n = 70 in each group). From the clinical notes, we generated datasets of single keywords and multi-word phrases, and constructed prediction models using a machine-learning algorithm based on a genetic programming framework. The resulting inference accuracy was consistently 65% or more. Our data therefore suggests that computerized text analytics can be applied to unstructured medical records to estimate the risk of suicide. The resulting system could allow clinicians to potentially screen seemingly healthy patients at the primary care level, and to continuously evaluate the suicide risk among psychiatric patients.     

An experimental study of GFP-based FRET, with application to intrinsically unstructured proteins

We have experimentally studied the fluorescence resonance energy transfer (FRET) between green fluorescent protein (GFP) molecules by inserting folded or intrinsically unstructured proteins between CyPet and Ypet. We discovered that most of the enhanced FRET signal previously reported for this pair was due to enhanced dimerization, so we engineered a monomerizing mutation into each. An insert containing a single fibronectin type III domain (3.7 nm end-to-end) gave a moderate FRET signal while a two-domain insert (7.0 nm) gave no FRET. We then tested unstructured proteins of various lengths, including the charged-plus-PQ domain of ZipA, the tail domain of alpha-adducin, and the C-terminal tail domain of FtsZ. The structures of these FRET constructs were also studied by electron microscopy and sedimentation. A 12 amino acid linker and the N-terminal 33 amino acids of the charged domain of the ZipA gave strong FRET signals. The C-terminal 33 amino acids of the PQ domain of the ZipA and several unstructured proteins with 66-68 amino acids gave moderate FRET signals. The 150 amino acid charged-plus-PQ construct gave a barely detectable FRET signal. FRET efficiency was calculated from the decreased donor emission to estimate the distance between donor and acceptor. The donor-acceptor distance varied for unstructured inserts of the same length, suggesting that they had variable stiffness (persistence length). We conclude that GFP-based FRET can be useful for studying intrinsically unstructured proteins, and we present a range of calibrated protein inserts to experimentally determine the distances that can be studied.     

Measuring and improving the quality of mental health care: a global perspective

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology‐based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient‐centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement‐based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.     

Decision-making in the leech nervous system

Previous models of behavioral choice have described two types of hierarchy, a decision hierarchy, in which different classes of decisions are made at each level (Tinbergen, 1951), and a behavioral hierarchy, in which one behavior will take precedence over others (Davis, 1985). Most experimental work on the neuronal basis of decision-making has focussed on the latter of these: a behavioral hierarchy is described for an animal, and the neuronal basis for this hierarchy, hypothesized to depend on inhibitory interactions, is investigated. Although the concept of "dedicated command neurons" has been useful for guiding these studies, it appears that such neurons are rare. We present evidence that in the leech, most neurons, including high-level decision neurons, are active in more than one behavior. We include data from one newly-identified neuron that elicits both swimming and crawling motor patterns. We suggest that decisions are made by a "combinatorial code": what behavior is produced depends on the specific combination of decision neurons that are active at a particular time. Finally, we discuss how decision neurons may be arranged into a decision hierarchy, with neurons at each sequential level responsible for choosing between a narrower range of behaviors. We suggest additional sensory information is incorporated at each level to inform the decision.     

A systematic review of re-identification attacks on health data

BackgroundPrivacy legislation in most jurisdictions allows the disclosure of health data for secondary purposes without patient consent if it is de-identified. Some recent articles in the medical, legal, and computer science literature have argued that de-identification methods do not provide sufficient protection because they are easy to reverse. Should this be the case, it would have significant and important implications on how health information is disclosed, including: (a) potentially limiting its availability for secondary purposes such as research, and (b) resulting in more identifiable health information being disclosed. Our objectives in this systematic review were to: (a) characterize known re-identification attacks on health data and contrast that to re-identification attacks on other kinds of data, (b) compute the overall proportion of records that have been correctly re-identified in these attacks, and (c) assess whether these demonstrate weaknesses in current de-identification methods.ConclusionsThe current evidence shows a high re-identification rate but is dominated by small-scale studies on data that was not de-identified according to existing standards. This evidence is insufficient to draw conclusions about the efficacy of de-identification methods.     

Case Study of an Integrated Framework for Quantifying Agroecosystem Health

Agroecosystem health derives from a combination of biophysical and socioeconomic conditions that jointly influence such properties as productivity, sustainability, stability, and equitability. In this case study, we describe and analyze a method to quantify agroecosystem health through a combination of geographically referenced data at various spatial scales. Six key variables were hypothesized to provide a minimum set of conditions required to quantify agroecosystem health: soil health, biodiversity, topography, farm economics, land economics, and social organization. Each of these key variables was quantified by one or more attributes of a study area near Wooster, Ohio. Data sources included remote sensing, digital elevation models, soil maps, county auditor records, and a structured questionnaire of landowners in the study area. These data were combined by an analytical hierarchy process to yield an agroecosystem health index. The two steps in the process were first to combine the data at the pixel scale (30 m²) into key variables with normalized values, and then to combine the key variables into the final index. The analytical hierarchy process model was developed by panels of experts for each key variable and by participants in the Ohio Agricultural Research and Development Center’s Agroecosystems Management Program for the final agroecosystem health index value. Observed spatial patterns of the agroecosystem health index were then analyzed with respect to the underlying data. Consistent with our hypothesis and the definition of agroecosystems, spatial patterns in the agroecosystem health index were an emergent property of combined socioeconomic and biophysical conditions not apparent in any of the underlying data or key variables. The method proposed in this study permits estimation of agroecosystem health as a function of specific underlying conditions, which combine in complex ways. Because values of the agroecosystem health index and the data underlying them can be analyzed for a particular landscape, the method proposed could be useful to policy makers, educators, service agencies, organizations, and the people who live in the area for finding opportunities to improve the health of their agroecosystem. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. ^†Dr. Ben Stinner is deceased     

Intrinsic dynamics of the partly unstructured PX domain from the Sendai virus RNA polymerase cofactor P

Despite their evident importance for function, dynamics of intrinsically unstructured proteins are poorly understood. Sendai virus phosphoprotein, cofactor of the RNA polymerase, contains a partly unstructured protein domain. The phosphoprotein X domain (PX) is responsible for binding the polymerase to the nucleocapsid assembling the viral RNA. For RNA synthesis, the interplay of the dynamics of the unstructured and structured PX subdomains is thought to drive progression of the RNA polymerase along the nucleocapsid. Here we present a detailed study of the dynamics of PX using hydrogen/deuterium exchange and different NMR relaxation measurements. In the unstructured subdomain, large amplitude fast motions were found to be fine-tuned by the presence of residues with short side chains. In the structured subdomain, where fast motions of both backbone and side chains are fairly restricted, the first helix undergoes slow conformational exchange corresponding to a local unfolding event. The other two helices, which represent the nucleocapsid binding site, were found to be more stable and to reorient with respect to each other, as probed by slow conformational exchange identified for residues on the third helix. The study illustrates the intrinsically differential dynamics of this partly unstructured protein and proposes the relation between these dynamics and its function.     

Case contamination in electronic health records based case‐control studies

Clinically relevant information from electronic health records (EHRs) permits derivation of a rich collection of phenotypes. Unlike traditionally designed studies where scientific hypotheses are specified a priori before data collection, the true phenotype status of any given individual in EHR‐based studies is not directly available. Structured and unstructured data elements need to be queried through preconstructed rules to identify case and control groups. A sufficient number of controls can usually be identified with high accuracy by making the selection criteria stringent. But more relaxed criteria are often necessary for more thorough identification of cases to ensure achievable statistical power. The resulting pool of candidate cases consists of genuine cases contaminated with noncase patients who do not satisfy the control definition. The presence of patients who are neither true cases nor controls among the identified cases is a unique challenge in EHR‐based case‐control studies. Ignoring case contamination would lead to biased estimation of odds ratio association parameters. We propose an estimating equation approach to bias correction, study its large sample property, and evaluate its performance through extensive simulation studies and an application to a pilot study of aortic stenosis in the Penn medicine EHR. Our method holds the promise of facilitating more efficient EHR studies by accommodating enlarged albeit contaminated case pools.     

Structural features of the full-length adaptor protein GADS in solution determined using small-angle X-ray scattering

The Grb2-related adaptor protein GADS plays a central role during the initial phases of signal transduction in T lymphocytes. GADS possesses N- and C-terminal Src homology 3 (SH3) domains flanking a central Src homology 2 (SH2) domain and a 126-residue region rich in glutamine and proline residues, presumed to be largely unstructured. The SH2 domain of GADS binds the adaptor protein LAT; the C-terminal SH3 domain pairs GADS to the adaptor protein SLP-76, whereas the function of the central region is unknown. High-resolution three-dimensional models are available for the isolated SH2 and C-terminal SH3 domains in complex with their respective binding partners, LAT and SLP-76. However, in part because of its intrinsic instability, there is no structural information for the entire GADS molecule. Here, we report the low-resolution structure of full-length GADS in solution using small-angle x-ray scattering (SAXS). Based on the SAXS data, complemented by gel filtration experiments, we show that full-length GADS is monomeric in solution and that its overall structural parameters are smaller than those expected for a protein with a long unstructured region. Ab initio and rigid body modeling of the SAXS data reveal that full-length GADS is a relatively compact molecule and that the potentially unstructured region retains a significant degree of structural order. The biological function of GADS is discussed based on its overall structure.     

Smart cards--the key to trustworthy health information systems.

Some 20 years after they were first developed, "smart cards" are set to play a crucial part in healthcare systems. Last year about a billion were supplied, mainly for use in the financial sector, but their special features make them of particular strategic importance for the health sector, where they offer a ready made solution to some key problems of security and confidentiality. This article outlines what smart cards are and why they are so important in managing health information. I discuss some of the unique features of smart cards that are of special importance in the development of secure and trustworthy health information systems. Smart cards would enable individuals'' identities to be authenticated and communications to be secured and would provide the mechanisms for implementing strong security, differential access to data, and definitive audit trails. Patient cards can also with complete security carry personal details, data on current health problems and medications, emergency care data, and pointers to where medical records for the patient can be found. Provider cards can in addition carry authorisations and information on computer set up.     

Atomistic ensemble modeling and small-angle neutron scattering of intrinsically disordered protein complexes: applied to minichromosome maintenance protein

The minichromosome maintenance (MCM) proteins are thought to function as the replicative helicases in archaea and eukarya. In this work we determined the solution structure of the N-terminal portion of the MCM complex from the archaeon Methanothermobacter thermautotrophicus (N-mtMCM) in the presence and absence of DNA using small-angle neutron scattering (SANS). N-mtMCM is a multimeric protein complex that consists of 12 monomers, each of which contains three distinct domains and two unstructured regions. Using an all-atom approach incorporating modern force field and Monte Carlo methods to allow the unstructured regions of each monomer to be varied independently, we generated an ensemble of biologically relevant structures for the complex. An examination of the subsets of structures that were most consistent with the SANS data revealed that large movements between the three domains of N-mtMCM can occur in solution. Furthermore, changes in the SANS curves upon DNA binding could be correlated to the motion of a particular N-mtMCM domain. These results provide structural support to the previously reported biochemical observations that large domain motions are required for the activation of the MCM helicase in archaea and eukarya. The methods developed here for N-mtMCM solution structure modeling should be suitable for other large protein complexes with unstructured flexible regions.     

Genetic parameters for serial, automatically recorded milkability and its relationship to udder health in dairy cattle

Serial measurements of three milkability traits from two commercial dairy farms in Germany were used to estimate heritabilities and breeding values (BVs). Overall, 6352 cows in first, second and third lactations supplied 2 188 810 records based on daily values recorded from 1998 to 2003. Only the records between day 8 and day 305 after calving were considered. The estimated genetic correlations between different parities within the three milkability traits ranged from rg = 0.88 to 0.98, i.e. they were sufficiently high to warrant a repeatability model. The resulting estimated heritability coefficients were h2 = 0.42 for average milk flow, h2 = 0.56 for maximum milk flow and h2 = 0.38 for milking time. We analysed the genetic correlation between milkability and somatic cell score (SCS) and between milkability and the liability to mastitis, respectively, as the optimum milk flow for udder health is not well defined. There were 66 146 records with information on somatic cell count. Furthermore, 23 488 days of medical treatment for udder diseases were available, resulting in 2 600 302 days of observation in total. Heritabilities for the liability to mastitis, estimated with a test-day threshold model, were h2 = 0.19 and h2 = 0.13, depending on the data-recording period (first 50 days of lactation and first 305 days of lactation, respectively). With respect to the relationship between milkability and udder health, the results indicated a slight and linear correlation insofar as one can assume: the higher the milk flow, the worse the udder health. For this reason, bulls and cows with high BVs for milk flow should be excluded from breeding to avoid a deterioration of udder health. The establishment of a special data-recording scheme for functional traits such as milkability and mastitis on commercial dairy farms may be possible according to these results.     

Domain architectures and characterization of an RNA-binding protein, TLS

Translocated in liposarcoma (TLS) is an important protein component of the heterogeneous nuclear ribonucleoprotein complex involved in the splicing of pre-mRNA and the export of fully processed mRNA to the cytoplasm. We examined the domain organization of human TLS by a combined approach using limited proteolysis, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, circular dichroism, inductively coupled plasma atomic emission spectroscopy, and NMR spectroscopy. We found that the RNA recognition motif (RRM) and zinc finger-like domains exclusively form protease-resistant core structures within the isolated TLS protein fragments, while the remaining regions, including the Arg-Gly-Gly repeats, appear to be completely unstructured. Thus, TLS contains the unstructured N-terminal half followed by the RRM and zinc finger-like domains, which are connected to each other by a flexible linker. We also carried out NMR analyses to obtain more detailed insights into the individual RRM and zinc finger-like domains. The 113Cd NMR analysis of the zinc finger-like domain verified that zinc is coordinated with four cysteines in the C4 type scheme. We also investigated the interaction of each domain with an oligo-RNA containing the GGUG sequence, which appears to be critical for the TLS function in splicing. The backbone amide NMR chemical shift perturbation analyses indicated that the zinc finger domain binds GGUG-containing RNA with a dissociation constant of about 1.0 x 10(-5) m, whereas the RRM domain showed no observable interaction with this RNA. This surprising result implies that the zinc finger domain plays a more predominant role in RNA recognition than the RRM domain.     

Biophysical characterization of the unstructured cytoplasmic domain of the human neuronal adhesion protein neuroligin 3

Cholinesterase-like adhesion molecules (CLAMs) are a family of neuronal cell adhesion molecules with important roles in synaptogenesis, and in maintaining structural and functional integrity of the nervous system. Our earlier study on the cytoplasmic domain of one of these CLAMs, the Drosophila protein, gliotactin, showed that it is intrinsically unstructured in vitro. Bioinformatic analysis suggested that the cytoplasmic domains of other CLAMs are also intrinsically unstructured, even though they bear no sequence homology to each other or to any known protein. In this study, we overexpress and purify the cytoplasmic domain of human neuroligin 3, notwithstanding its high sensitivity to the Escherichia coli endogenous proteases that cause its rapid degradation. Using bioinformatic analysis, sensitivity to proteases, size exclusion chromatography, fluorescence correlation spectroscopy, analytical ultracentrifugation, small angle x-ray scattering, circular dichroism, electron spin resonance, and nuclear magnetic resonance, we show that the cytoplasmic domain of human neuroligin 3 is intrinsically unstructured. However, several of these techniques indicate that it is not fully extended, but becomes significantly more extended under denaturing conditions.     

Electronic health records: the European scene.

Caring for patients'' health problems relies increasingly on sharing information between clinical departments and disciplines and with managers. The medical record of the future will need to provide a flexible and shareable framework for recording and analysing the consultation process. The advanced informatics in medicine (AIM) programme seeks to encourage research and development in telemedicine in areas that are beyond the scope of any one country. It includes many European projects attempting to define the best storage and transmission formats for such diverse data types as laboratory results, biosignals, x ray images, and photographs, and in clinical specialties varying from intensive care to medicine for elderly people. One example, the good European health record project, is developing a model architecture for computerised health records across Europe that is capable of operating on a wide variety of computer hardwares and will also be able to communicate with many different information systems. The ultimate European health record will be comprehensive and medicolegally acceptable across clinical domains, hold all data types, and be automatically translated between languages.     

Quaternary ammonium compounds as structural probes of single batrachotoxin-activated Na+ channels

Quaternary ammonium (QA) blockers are well-known structural probes for studying the permeation pathway of voltage-gated K+ channels. In this study we have examined the effects of a series of n-alkyl-trimethylammonium compounds (Cn-QA) on batrachotoxin (BTX)-activated Na+ channels from skeletal muscle incorporated into planar lipid bilayers. We found that these amphipathic QA compounds (Cn-QA where n = 10-18) block single Na+ channels preferentially from the internal side with equilibrium dissociation constants (KD) in the submicromolar to micromolar range. External application of amphipathic QA compounds is far less effective, by a factor of greater than 200. The block can be described by a QA molecule binding to a single site in the Na+ channel permeation pathway. QA binding affinity is dependent on transmembrane voltage with an effective valence (delta) of approximately 0.5. QA dwell times (given as mean closed times, tau c) increase as a function of n-alkyl chain length, ranging from approximately 13 ms for C10-QA to 500 ms for C18-QA at +50 mV. The results imply that there is a large hydrophobic region within the Na+ channel pore which accepts up to 18 methylene groups of the Cn-QA cation. This hydrophobic domain may be of clinical significance since it also interacts with local anesthetics such as cocaine and mepivacaine. Finally, like BTX-activated Na+ channels in bilayers, unmodified Na+ channels in GH3 cells are also susceptible to QA block. Amphipathic QA cations elicit both tonic and use-dependent inhibitions of normal Na+ currents in a manner similar to that of local anesthetic cocaine. We conclude that amphipathic QA compounds are valuable structural probes to study the permeation pathway of both normal and BTX-activated Na+ channels.