A chatbot for hypertension self-management support: user-centered design, development, and usability testing

Objectives

Health-related chatbots have demonstrated early promise for improving self-management behaviors but have seldomly been utilized for hypertension. This research focused on the design, development, and usability evaluation of a chatbot for hypertension self-management, called "Medicagent."

Materials and Methods

A user-centered design process was used to iteratively design and develop a text-based chatbot using Google Cloud's Dialogflow natural language understanding platform. Then, usability testing sessions were conducted among patients with hypertension. Each session was comprised of: (1) background questionnaires, (2) 10 representative tasks within Medicagent, (3) System Usability Scale (SUS) questionnaire, and (4) a brief semi-structured interview. Sessions were video and audio recorded using Zoom. Qualitative and quantitative analyses were used to assess effectiveness, efficiency, and satisfaction of the chatbot.

Results

Participants (n = 10) completed nearly all tasks (98%, 98/100) and spent an average of 18 min (SD = 10 min) interacting with Medicagent. Only 11 (8.6%) utterances were not successfully mapped to an intent. Medicagent achieved a mean SUS score of 78.8/100, which demonstrated acceptable usability. Several participants had difficulties navigating the conversational interface without menu and back buttons, felt additional information would be useful for redirection when utterances were not recognized, and desired a health professional persona within the chatbot.

Discussion

The text-based chatbot was viewed favorably for assisting with blood pressure and medication-related tasks and had good usability.

Conclusion

Flexibility of interaction styles, handling unrecognized utterances gracefully, and having a credible persona were highlighted as design components that may further enrich the user experience of chatbots for hypertension self-management.

Electronic Health Record Use and Perceptions among Urologic Surgeons

OBJECTIVE

Electronic health records (EHRs) have become widely adopted with increasing emphasis on improving care delivery. Improvements in surgery may be limited by specialty-specific issues that impact EHR usability and engagement. Accordingly, we examined EHR use and perceptions in urology, a diverse surgical specialty.

METHODS

We conducted a national, sequential explanatory mixed methods study. Through the 2019 American Urological Association Census, we surveyed urologic surgeons on EHR use and perceptions and then identified associated characteristics through bivariable and multivariable analyses. Using purposeful sampling, we interviewed 25 urologists and applied coding-based thematic analysis, which was then integrated with survey findings.

RESULTS

Among 2,159 practicing urologic surgeons, 2,081 (96.4%) reported using an EHR. In the weighted sample (n = 12,366), over 90% used the EHR for charting, viewing results, and order entry with most using information exchange functions (59.0-79.6%). In contrast, only 35.8% felt the EHR increases clinical efficiency, whereas 43.1% agreed it improves patient care, which related thematically to information management, administrative burden, patient safety, and patient-surgeon interaction. Quantitatively and qualitatively, use and perceptions differed by years in practice and practice type with more use and better perceptions among more recent entrants into the urologic workforce and those in academic/multispecialty practices, who may have earlier EHR exposure, better infrastructure, and more support.

CONCLUSION

Despite wide and substantive usage, EHRs engender mixed feelings, especially among longer-practicing surgeons and those in lower-resourced settings (e.g., smaller and private practices). Beyond reducing administrative burden and simplifying information management, efforts to improve care delivery through the EHR should focus on surgeon engagement, particularly in the community, to boost implementation and user experience.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis

STUDY OBJECTIVE

An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings.

METHODS

On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis.

RESULTS

A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED.

CONCLUSION

In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Health information technology to support cancer survivorship care planning: A systematic review

OBJECTIVE

The study sought to conduct a systematic review to explore the functions utilized by electronic cancer survivorship care planning interventions and assess their effects on patient and provider outcomes.

MATERIALS AND METHODS

Based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, studies published from January 2000 to January 2020 were identified in PubMed, CINAHL, EMBASE, PsychINFO, Scopus, Web of Science, and the ACM Digital Library . The search combined terms for cancer, survivorship, care planning, and health information technology (HIT). Eligible studies evaluated the effects of a HIT intervention on usability, knowledge, process, or health-related outcomes. A total of 578 abstracts were reviewed, resulting in 60 manuscripts describing 40 studies. Thematic analyses were used to define meta-themes of system functions, and Fisher's exact tests were used to examine associations between functions and outcomes.

RESULTS

Patients were the target end users for 18 interventions, while 12 targeted providers and 10 targeted both groups. Interventions used patient-reported outcomes collection (60%), automated content generation (58%), electronic sharing (40%), persistent engagement (28%), and communication features (20%). Overall, interventions decreased the time to create survivorship care plans (SCPs) and supported care planning knowledge and abilities, but results were mixed for effects on healthcare utilization, SCP sharing, and provoking anxiety. Persistent engagement features were associated with improvements in health or quality-of-life outcomes (17 studies, P = .003).

CONCLUSIONS

Features that engaged users persistently over time were associated with better health and quality-of-life outcomes. Most systems have not capitalized on the potential of HIT to share SCPs across a care team and support care coordination.

Information needs and perceptions of chatbots for hypertension medication self-management: a mixed methods study

Objective

Chatbots have potential to deliver interactive self-management interventions but have rarely been studied in the context of hypertension or medication adherence. The objective of this study was to better understand patient information needs and perceptions of chatbots to support hypertension medication self-management.

Materials and Methods

Mixed methods were used to assess self-management needs and preferences for using chatbots. We purposively sampled adults with hypertension who were prescribed at least one medication. Participants completed questionnaires on sociodemographics, health literacy, self-efficacy, and technology use. Semi-structured interviews were conducted, audio-recorded, and transcribed verbatim. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using applied thematic analysis.

Results

Thematic saturation was met after interviewing 15 participants. Analysis revealed curiosity toward chatbots, and most perceived them as humanlike. The majority were interested in using a chatbot to help manage medications, refills, communicate with care teams, and for accountability toward self-care tasks. Despite general enthusiasm, there were concerns with chatbots providing too much information, making demands for lifestyle changes, invading privacy, and usability issues with deployment on smartphones. Those with overall positive perceptions toward chatbots were younger and taking fewer medications.

Discussion

Chatbot-related informational needs were consistent with existing self-management research, and many felt chatbots would be valuable if customizable and compatible with patient portals, pharmacies, or health apps.

Conclusion

Although most were not familiar with chatbots, patients were interested in interacting with them, but this varied. This research informs future design and functionalities of conversational interfaces to support hypertension self-management.

Gender representation in U.S. biomedical informatics leadership and recognition

OBJECTIVE

This study sought to describe gender representation in leadership and recognition within the U.S. biomedical informatics community.

MATERIALS AND METHODS

Data were collected from public websites or provided by American Medical Informatics Association (AMIA) personnel from 2017 to 2019, including gender of membership, directors of academic informatics programs, clinical informatics subspecialty fellowships, AMIA leadership (2014-2019), and AMIA awardees (1993-2019). Differences in gender proportions were calculated using chi-square tests.

RESULTS

Men were more often in leadership positions and award recipients (P < .01). Men led 74.7% (n = 71 of 95) of academic informatics programs and 83.3% (n = 35 of 42) of clinical informatics fellowships. Within AMIA, men held 56.8% (n = 1086 of 1913) of leadership roles and received 64.1% (n = 59 of 92) of awards.

DISCUSSION

As in other STEM fields, leadership and recognition in biomedical informatics is lower for women.

CONCLUSIONS

Quantifying gender inequity should inform data-driven strategies to foster diversity and inclusion. Standardized collection and surveillance of demographic data within biomedical informatics is necessary.

Conversational Agents for Chronic Disease Self-Management: A Systematic Review

We conducted a systematic literature review to assess how conversational agents have been used to facilitate chronic disease self-management. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework was used. Literature was searched across five databases, and we included full-text articles that contained primary research findings for text-based conversational agents focused on self-management for chronic diseases in adults. 1,606 studies were identified, and 12 met inclusion criteria. Outcomes were largely focused on usability of conversational agents, and participants mostly reported positive attitudes with some concerns related to privacy and shallow content. In several studies, there were improvements on the Patient Health Questionnaire (p<0.05), Generalized Anxiety Disorder Scale (p=0.004), Perceived Stress Scale (p=0.048), Flourishing Scale (p=0.032), and Overall Anxiety Severity and Impairment Scale (p<0.05). There is early evidence that suggests conversational agents are acceptable, usable, and may be effective in supporting self-management, particularly for mental health.

Feasibility and delivery of patient-reported outcomes in clinical practice among racially diverse bladder and prostate cancer patients

OBJECTIVE

To assess the feasibility of enrollment and collecting patient-reported outcome (PRO) data as part of routine clinical urologic care for bladder and prostate cancer patients and examine overall patterns and racial variations in PRO use and symptom reports over time.

SUBJECTS/PATIENTS AND METHODS

We recruited 76 patients (n = 29 Black and n = 47 White) with prostate or bladder cancer at a single, comprehensive cancer center. The majority of prostate cancer patients had intermediate risk (57%) disease and underwent either radiation or prostatectomy. Over half (58%) of bladder cancer patients had muscle invasive disease and underwent cystectomy. Patients were asked to complete PRO symptom surveys using their preferred mode [web- or phone-based interactive voice response (IVR)]. Symptom summary reports were shared with providers during visits. Surveys were completed at 3 time points and assessed urinary, sexual, gastrointestinal, anxiety/depression, and sleep symptoms. Feasibility of enrollment and survey completion were calculated, and linear mixed effects models estimated differences in outcomes by race and time.

RESULTS

Sixty three percent of study participants completed all PRO measures at all 3 time points. Black patients were more likely to select IVR as their survey mode (40% vs. 13%, P < 0.05), and less likely to complete all surveys (55% vs. 74%, P = 0.13). Patients using IVR were also less likely to complete all surveys (41% vs. 69%, P = 0.046).

CONCLUSIONS

Reported preferences for survey mode and completion rates differ by race, which may influence survey completion rates and highlight potential obstacles for equitable implementation of PROs into clinical care.

From Patient Engagement to Precision Oncology: Leveraging Informatics to Advance Cancer Care

OBJECTIVES

Conduct a survey of the literature for advancements in cancer informatics over the last three years in three specific areas where there has been unprecedented growth: 1) digital health; 2) machine learning; and 3) precision oncology. We also highlight the ethical implications and future opportunities within each area.

METHODS

A search was conducted over a three-year period in two electronic databases (PubMed, Google Scholar) to identify peer-reviewed articles and conference proceedings. Search terms included variations of the following: neoplasms[MeSH], informatics[MeSH], cancer, oncology, clinical cancer informatics, medical cancer informatics. The search returned too many articles for practical review (23,994 from PubMed and 23,100 from Google Scholar). Thus, we conducted searches of key PubMed-indexed informatics journals and proceedings. We further limited our search to manuscripts that demonstrated a clear focus on clinical or translational cancer informatics. Manuscripts were then selected based on their methodological rigor, scientific impact, innovation, and contribution towards cancer informatics as a field or on their impact on cancer care and research.

RESULTS

Key developments and opportunities in cancer informatics research in the areas of digital health, machine learning, and precision oncology were summarized.

CONCLUSION

While there are numerous innovations in the field of cancer informatics to advance prevention and clinical care, considerable challenges remain related to data sharing and privacy, digital accessibility, and algorithm biases and interpretation. The implementation and application of these findings in cancer care necessitates further consideration and research.

Abstract C007: Racial differences in feasibility and perceived value of electronic symptom monitoring in a cohort of Black and White bladder and prostate cancer patients

Background Racial differences in cancer-related symptom burden are well-documented, and partly linked to inequities in symptom monitoring. Electronic patient-reported outcomes (ePROs) are useful for symptom monitoring, but have rarely been evaluated in diverse patient populations. We implemented an ePRO tool among a cohort of Black and White cancer patients and evaluated (1) whether ePRO use was perceived as feasible and valuable for symptom management; and (2) if perceptions of feasibility and value differed by race. Methods We recruited 30 Black and 50 White bladder and prostate cancer patients from a single institution. Participants completed ePRO assessments prior to, during, and 3 months following completion of cancer treatment. Participants were given the option of reporting symptoms using a web- or phone-based system. A subset of participants completed end-of-study satisfaction surveys (n=9 Black; n=25 White) and qualitative interviews (n=15 Black; n=25 White) assessing ePRO feasibility and value. We analyzed end-of-study surveys and qualitative interview data, evaluating race-specific differences in user experiences with the ePRO tool. Results Both Black (77.8%) and White (96.0%) participants more commonly reported using the web-based system for symptom reporting, with the majority of participants reporting being “very satisfied” with the web-based system (71.4% Black; 66.7% White). Whites more commonly reported high levels of ease in understanding and answering symptom assessment items compared with Blacks (44.4% Black; 56.0% White). In interviews, Blacks expressed stronger preferences for phone-based and paper-based reporting due to ease in facilitating understanding of symptom items. In terms of perceived value, Blacks more often reported that the ePRO tool was “very helpful” in reminding them of symptoms experienced in the last seven days (55.6% Black; 36.0% White). In interviews, Blacks also described how the ePRO helped them better understand symptoms, while Whites noted finding value in better understanding symptoms and the ability to track their symptoms over time. Black and White respondents commonly reported that doctors communicated with them about ePRO-reported symptoms (88.9% Black; 84.0% White), but Blacks more often reported that the ePRO tool was “very helpful” in speaking to doctors about symptoms (44.4% Black; 24.0% White). In interviews, both Black and White participants indicated that ePRO use prompted more in-depth discussions about symptoms and treatment options with providers. Conclusion Electronic symptom monitoring is perceived as valuable among Black and White cancer patients. Greater perceived value of ePROs among Blacks may have implications for addressing systemic drivers of symptom disparities. As oncology practices move towards broader implementation of ePROs, it will be important to consider the health literacy needs and ePRO modality preferences of patients, in order to promote equitable adoption of electronic symptom monitoring.

Citation Format: Cleo A. Samuel, Angela Smith, Ronald Chen, Wendi Elkins, Jennifer Richmond, Zahra Mahbooba, Dana E. Mueller, Ethan Basch, Antonia V. Bennett, Arlene E. Chung, Bryce B. Reeve. Racial differences in feasibility and perceived value of electronic symptom monitoring in a cohort of Black and White bladder and prostate cancer patients [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C007.

Citizen science to further precision medicine: from vision to implementation

The active involvement of citizen scientists in setting research agendas, partnering with academic investigators to conduct research, analyzing and disseminating results, and implementing learnings from research can improve both processes and outcomes. Adopting a citizen science approach to the practice of precision medicine in clinical care and research will require healthcare providers, researchers, and institutions to address a number of technical, organizational, and citizen scientist collaboration issues. Some changes can be made with relative ease, while others will necessitate cultural shifts, redistribution of power, recommitment to shared goals, and improved communication. This perspective, based on a workshop held at the 2018 AMIA Annual Symposium, identifies current barriers and needed changes to facilitate broad adoption of a citizen science-based approach in healthcare.

Health Tracking and Information Sharing in the Patient-Centered Era: A Health Information National Trends Survey (HINTS) Study

We examined the current state of digital health tracking and information sharing with health professionals among patients with chronic conditions using data from the National Cancer Institute's 2018 Health Information National Trends Survey (HINTS). Descriptive statistics were used to examine the characteristics of health tracking and information sharing, Chi-squared tests were used to compare across groups, and multivariate logistic regression models were used to control for covariates. Between 17.4-37.6% of respondents reported sharing information with a health professional through either e-mail, monitoring device, text message, or online medical record message. There were sociodemographic differences across health tracking and information sharing modalities, and patients with chronic conditions disproportionately lacked Internet access, a basic cell phone, smartphone, or tablet compared to those without chronic conditions (p<0.05). This suggests there are sociodemographic and technology-based disparities for health tracking and information sharing for patients with chronic conditions.

Performance Measures Based on How Adults With Cancer Feel and Function: Stakeholder Recommendations and Feasibility Testing in Six Cancer Centers

PURPOSE

Patient-reported outcome measures (PROMs) that assess how patients feel and function have potential for evaluating quality of care. Stakeholder recommendations for PRO-based performance measures (PMs) were elicited, and feasibility testing was conducted at six cancer centers.

METHODS

Interviews were conducted with 124 stakeholders to determine priority symptoms and risk adjustment variables for PRO-PMs and perceived acceptability. Stakeholders included patients and advocates, caregivers, clinicians, administrators, and thought leaders. Feasibility testing was conducted in six cancer centers. Patients completed PROMs at home 5-15 days into a chemotherapy cycle. Feasibility was operationalized as ≥ 75% completed PROMs and ≥ 75% patient acceptability.

RESULTS

Stakeholder priority PRO-PMs for systemic therapy were GI symptoms (diarrhea, constipation, nausea, vomiting), depression/anxiety, pain, insomnia, fatigue, dyspnea, physical function, and neuropathy. Recommended risk adjusters included demographics, insurance type, cancer type, comorbidities, emetic risk, and difficulty paying bills. In feasibility testing, 653 patients enrolled (approximately 110 per site), and 607 (93%) completed PROMs, which indicated high feasibility for home collection. The majority of patients (470 of 607; 77%) completed PROMs without a reminder call, and 137 (23%) of 607 completed them after a reminder call. Most patients (72%) completed PROMs through web, 17% paper, or 2% interactive voice response (automated call that verbally asked patient questions). For acceptability, > 95% of patients found PROM items to be easy to understand and complete.

CONCLUSION

Clinicians, patients, and other stakeholders agree that PMs that are based on how patients feel and function would be an important addition to quality measurement. This study also shows that PRO-PMs can be feasibly captured at home during systemic therapy and are acceptable to patients. PRO-PMs may add value to the portfolio of PMs as oncology transitions from fee-for-service payment models to performance-based care that emphasizes outcome measures.

Patient free text reporting of symptomatic adverse events in cancer clinical research using the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE)

OBJECTIVE

The study sought to describe patient-entered supplemental information on symptomatic adverse events (AEs) in cancer clinical research reported via a National Cancer Institute software system and examine the feasibility of mapping these entries to established terminologies.

MATERIALS AND METHODS

Patients in 3 multicenter trials electronically completed surveys during cancer treatment. Each survey included a prespecified subset of items from the National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Upon completion of the survey items, patients could add supplemental symptomatic AE information in a free text box. As patients typed into the box, structured dropdown terms could be selected from the PRO-CTCAE item library or Medical Dictionary for Regulatory Activities (MedDRA), or patients could type unstructured free text for submission.

RESULTS

Data were pooled from 1760 participants (48% women; 78% White) who completed 8892 surveys, of which 2387 (26.8%) included supplemental symptomatic AE information. Overall, 1024 (58%) patients entered supplemental information at least once, with an average of 2.3 per patient per study. This encompassed 1474 of 8892 (16.6%) dropdowns and 913 of 8892 (10.3%) unstructured free text entries. One-third of the unstructured free text entries (32%) could be mapped post hoc to a PRO-CTCAE term and 68% to a MedDRA term.

DISCUSSION

Participants frequently added supplemental information beyond study-specific survey items. Almost half selected a structured dropdown term, although many opted to submit unstructured free text entries. Most free text entries could be mapped post hoc to PRO-CTCAE or MedDRA terms, suggesting opportunities to enhance the system to perform real-time mapping for AE reporting.

CONCLUSIONS

Patient reporting of symptomatic AEs using a text box functionality with mapping to existing terminologies is both feasible and informative.

Development of the influence, motivation, and patient activation in diabetes (IMPACT-D™) measure

AIMS

We sought to create a new research and clinical instrument -the Influence and Motivation for Patient ACTivation in Diabetes care (IMPACT-D™) - to measure the degree to which patients with type 2 diabetes (T2DM) value health and believe they can influence it.

METHODS

Candidate items were generated via a literature review, expert opinion, and qualitative interviews and focus groups with T2DM patients in Chicago, IL and Chapel Hill, NC. Psychometric testing guided by item response theory was conducted among an online panel of 500 English-speaking adults with T2DM. Differential item functioning analyses evaluated item performance across key participant characteristics. To determine construct validity, IMPACT-D™ scores were compared to other general measures of personality and patient activation. A second study among 300 patients recruited from two internal medicine clinics further assessed associations between the IMPACT-D™ and health outcomes. Cognitive interviews confirmed patient understanding of IMPACT-D™ items and instructions.

RESULTS

Exploratory factor analyses revealed a single-factor solution that included 6 items. The IMPACT-D™ demonstrated adequate reliability (α = 0.72) and moderate construct validity with patient activation (r = 0.51, p < 0.001) and personality-conscientiousness subscales (r = 0.29, p < 0.001). Higher scores on the IMPACT-D™ were associated with better physical health (r = 0.17, p = 0.003) and lower severity of depressive (r = -0.35, p < 0.001) and anxiety (r = -0.28, p < 0.001) symptoms. There were no significant differences by blood pressure (r = -0.0021, p = 0.9) or haemoglobin A1c (r = -0.069p = 0.2).

CONCLUSIONS

The IMPACT-D holds potential for use in both clinical care and research applications. Future studies should evaluate how to best operationalize its use for both settings.

Electronic Health Record-Based Strategy to Promote Medication Adherence Among Patients With Diabetes: Longitudinal Observational Study

Background

Poor medication adherence is common; however, few mechanisms exist in clinical practice to monitor how patients take medications in outpatient settings.

Objective

This study aimed to pilot test the Electronic Medication Complete Communication (EMC²) strategy, a low-cost, sustainable approach that uses functionalities within the electronic health record to promote outpatient medication adherence and safety.

Methods

The EMC² strategy was implemented in 2 academic practices for 14 higher-risk diabetes medications. The strategy included: (1) clinical decision support alerts to prompt provider counseling on medication risks, (2) low-literacy medication summaries for patients, (3) a portal-based questionnaire to monitor outpatient medication use, and (4) clinical outreach for identified concerns. We recruited adult patients with diabetes who were prescribed a higher-risk diabetes medication. Participants completed baseline and 2-week interviews to assess receipt of, and satisfaction with, intervention components.

Results

A total of 100 patients were enrolled; 90 completed the 2-week interview. Patients were racially diverse, 30.0% (30/100) had a high school education or less, and 40.0% (40/100) had limited literacy skills. About a quarter (28/100) did not have a portal account; socioeconomic disparities were noted in account ownership by income and education. Among patients with a portal account, 58% (42/72) completed the questionnaire; 21 of the 42 patients reported concerns warranting clinical follow-up. Of these, 17 were contacted by the clinic or had their issue resolved within 24 hours. Most patients (33/38, 89%) who completed the portal questionnaire and follow-up interview reported high levels of satisfaction (score of 8 or greater on a scale of 1-10).

Conclusions

Findings suggest that the EMC² strategy can be reliably implemented and delivered to patients, with high levels of satisfaction. Disparities in portal use may restrict intervention reach. Although the EMC² strategy can be implemented with minimal impact on clinic workflow, future trials are needed to evaluate its effectiveness to promote adherence and safety.

Opportunities and challenges to advance the use of electronic patient-reported outcomes in clinical care: a report from AMIA workshop proceedings

Despite the demonstrated value of patient-centered care, health systems have been slow to integrate the patient’s voice into care delivery through patient-reported outcomes (PROs) with electronic tools. This is due in part to the complex interplay of technology, workflow, and human factors that shape the success of electronic PROs (ePROs) use. The 2018 American Medical Informatics Association Annual Symposium served as the setting for a half-day interactive workshop with diverse stakeholders to discuss proposed best practices for the planning, design, deployment, and evaluation of ePROs. We provide this collective commentary that synthesizes participant feedback regarding critical challenges that prohibit the scale and spread of ePROs across healthcare delivery systems, including governance and leadership, workflow and human factors, informatics, and data science. In order to realize the promise of ePROs at scale, adaptable approaches are critical to balance the needs of individual users with health systems at large.

Crohn's and Colitis Foundation of America Partners Patient-Powered Research Network: Patient Perspectives on Facilitators and Barriers to Building an Impactful Patient-Powered Research Network

BACKGROUND

To build a Patient-Powered Research Networks (PPRN) that prioritizes the needs of its members who have inflammatory bowel diseases (IBD), we sought to better understand patients' preferences for what are the essential features that will facilitate and sustain engagement.

METHODS

We conducted a two-phase qualitative study. Seven focus groups involving 62 participants with IBD were conducted (phase 1). Focus group results informed the phase 2 cognitive interviews, which included 13 phone interviews. Topics included experiences with IBD and research, PPRN engagement, patient-generated health data, and resources/tools to facilitate self-management. All focus groups and interviews were digitally recorded, transcribed verbatim, and analyzed in ATLAS.ti 7.5. Thematic categories were derived from the data, and codes were grouped into emergent themes and relationships.

RESULTS

Four major themes emerged through inductive coding: (1) the impact of knowing; (2) participation barriers and challenges; (3) engagement and collaboration; and (4) customizable patient portal features/functionalities. Participants were motivated to participate in the PPRN because the knowledge gained from research studies would benefit both society and the individual. Main concerns included credibility of online resources, pharmaceutical industry profiting from their data, data security, and participation expectations. Participants wanted a true and equal partnership in every phase of building a PPRN. Participants felt it was important to have access to personal health records and be able to track health status and symptoms.

CONCLUSION

Partnering with participants throughout PPRN development was critical to understanding the needs and preferences of patients with IBDs and for shaping engagement strategies and the portal's design.

Health and Fitness Apps for Hands-Free Voice-Activated Assistants: Content Analysis

Background

Hands-free voice-activated assistants and their associated devices have recently gained popularity with the release of commercial products, including Amazon Alexa and Google Assistant. Voice-activated assistants have many potential use cases in healthcare including education, health tracking and monitoring, and assistance with locating health providers. However, little is known about the types of health and fitness apps available for voice-activated assistants as it is an emerging market.

Objective

This review aimed to examine the characteristics of health and fitness apps for commercially available, hands-free voice-activated assistants, including Amazon Alexa and Google Assistant.

Methods

Amazon Alexa Skills Store and Google Assistant app were searched to find voice-activated assistant apps designated by vendors as health and fitness apps. Information was extracted for each app including name, description, vendor, vendor rating, user reviews and ratings, cost, developer and security policies, and the ability to pair with a smartphone app and website and device. Using a codebook, two reviewers independently coded each app using the vendor’s descriptions and the app name into one or more health and fitness, intended age group, and target audience categories. A third reviewer adjudicated coding disagreements until consensus was reached. Descriptive statistics were used to summarize app characteristics.

Results

Overall, 309 apps were reviewed; health education apps (87) were the most commonly occurring, followed by fitness and training (72), nutrition (33), brain training and games (31), and health monitoring (25). Diet and calorie tracking apps were infrequent. Apps were mostly targeted towards adults and general audiences with few specifically geared towards patients, caregivers, or medical professionals. Most apps were free to enable or use and 18.1% (56/309) could be paired with a smartphone app and website and device; 30.7% (95/309) of vendors provided privacy policies; and 22.3% (69/309) provided terms of use. The majority (36/42, 85.7%) of Amazon Alexa apps were rated by the vendor as mature or guidance suggested, which were geared towards adults only. When there was a user rating available, apps had a wide range of ratings from 1 to 5 stars with a mean of 2.97. Google Assistant apps did not have user reviews available, whereas most of Amazon Alexa apps had at least 1-9 reviews available.

Conclusions

The emerging market of health and fitness apps for voice-activated assistants is still nascent and mainly focused on health education and fitness. Voice-activated assistant apps had a wide range of content areas but many published in the health and fitness categories did not actually have a clear health or fitness focus. This may, in part, be due to Amazon and Google policies, which place restrictions on the delivery of care or direct recording of health data. As in the mobile app market, the content and functionalities may evolve to meet growing demands for self-monitoring and disease management.

Software for Administering the National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events: Usability Study

Background

The US National Cancer Institute (NCI) developed software to gather symptomatic adverse events directly from patients participating in clinical trials. The software administers surveys to patients using items from the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) through Web-based or automated telephone interfaces and facilitates the management of survey administration and the resultant data by professionals (clinicians and research associates).

Objective

The purpose of this study was to iteratively evaluate and improve the usability of the PRO-CTCAE software.

Methods

Heuristic evaluation of the software functionality was followed by semiscripted, think-aloud protocols in two consecutive rounds of usability testing among patients with cancer, clinicians, and research associates at 3 cancer centers. We conducted testing with patients both in clinics and at home (remotely) for both Web-based and telephone interfaces. Furthermore, we refined the software between rounds and retested.

Results

Heuristic evaluation identified deviations from the best practices across 10 standardized categories, which informed initial software improvement. Subsequently, we conducted user-based testing among 169 patients and 47 professionals. Software modifications between rounds addressed identified issues, including difficulty using radio buttons, absence of survey progress indicators, and login problems (for patients) as well as scheduling of patient surveys (for professionals). The initial System Usability Scale (SUS) score for the patient Web-based interface was 86 and 82 (P=.22) before and after modifications, respectively, whereas the task completion score was 4.47, which improved to 4.58 (P=.39) after modifications. Following modifications for professional users, the SUS scores improved from 71 to 75 (P=.47), and the mean task performance improved significantly (4.40 vs 4.02; P=.001).

Conclusions

Software modifications, informed by rigorous assessment, rendered a usable system, which is currently used in multiple NCI-sponsored multicenter cancer clinical trials.

Trial Registration

ClinicalTrials.gov NCT01031641; https://clinicaltrials.gov/ct2/show/NCT01031641 (Archived by WebCite at http://www.webcitation.org/708hTjlTl)

Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records

Digital engagement has become pervasive in the delivery of cancer care. Internet- and cellular phone-based tools and systems are allowing large groups of people to engage with each other and share information. Health systems and individual health professionals are adapting to this revolution in consumer and patient behavior by developing ways to incorporate the benefits of technology for the purpose of improving the quality of medical care. One example is the use of social media platforms by oncologists to foster interaction with each other and to participate with the lay public in dialogue about science, medicine, and cancer care. In addition, consumer devices and sensors (wearables) have provided a new, growing dimension of digital engagement and another layer of patient-generated health data to foster better care and research. Finally, electronic health records have become the new standard for oncology care delivery, bringing new opportunities to measure quality in real time and follow practice patterns, as well as new challenges as providers and patients seek ways to integrate this technology along with other forms of digital engagement to produce more satisfaction in the process of care along with measurably better outcomes.

Tweeting to Health: A Novel mHealth Intervention Using Fitbits and Twitter to Foster Healthy Lifestyles

We developed and pilot tested a mHealth intervention, "Tweeting to Health," which used Fitbits, Twitter, and gamification to facilitate support for healthy lifestyle changes in overweight/obese (OW) and healthy weight (HW) young adults. Participants tracked activity and diet using Fitbits and used Twitter for messaging for 2 months. Physical activity, dietary intake, and Tweets were tracked and participants completed surveys at enrollment, 1 month, and 2 months. Descriptive statistics were used to examine steps/day, physical activity intensity, lifestyle changes, and total Tweets. Participants were on average 19 to 20 years old and had familiarity with Twitter. OW participants had on average 11 222 daily steps versus 11 686 (HW). One-day challenges were successful in increasing steps. Participants increased fruit/vegetable intake (92%) and decreased their sugar-sweetened beverage intake (67%). Compliance with daily Fitbit wear (99% of all days OW vs 73% HW) and daily dietary logging (82% OW vs 73% HW) and satisfaction was high.

Using Technology to Improve Cancer Care: Social Media, Wearables, and Electronic Health Records

Digital engagement has become pervasive in the delivery of cancer care. Internet- and cellular phone-based tools and systems are allowing large groups of people to engage with each other and share information. Health systems and individual health professionals are adapting to this revolution in consumer and patient behavior by developing ways to incorporate the benefits of technology for the purpose of improving the quality of medical care. One example is the use of social media platforms by oncologists to foster interaction with each other and to participate with the lay public in dialogue about science, medicine, and cancer care. In addition, consumer devices and sensors (wearables) have provided a new, growing dimension of digital engagement and another layer of patient-generated health data to foster better care and research. Finally, electronic health records have become the new standard for oncology care delivery, bringing new opportunities to measure quality in real time and follow practice patterns, as well as new challenges as providers and patients seek ways to integrate this technology along with other forms of digital engagement to produce more satisfaction in the process of care along with measurably better outcomes.

Harnessing person-generated health data to accelerate patient-centered outcomes research: the Crohn's and Colitis Foundation of America PCORnet Patient Powered Research Network (CCFA Partners)

The Crohn's and Colitis Foundation of America Partners Patient-Powered Research Network (PPRN) seeks to advance and accelerate comparative effectiveness and translational research in inflammatory bowel diseases (IBDs). Our IBD-focused PCORnet PPRN has been designed to overcome the major obstacles that have limited patient-centered outcomes research in IBD by providing the technical infrastructure, patient governance, and patient-driven functionality needed to: 1) identify, prioritize, and undertake a patient-centered research agenda through sharing person-generated health data; 2) develop and test patient and provider-focused tools that utilize individual patient data to improve health behaviors and inform health care decisions and, ultimately, outcomes; and 3) rapidly disseminate new knowledge to patients, enabling them to improve their health. The Crohn's and Colitis Foundation of America Partners PPRN has fostered the development of a community of citizen scientists in IBD; created a portal that will recruit, retain, and engage members and encourage partnerships with external scientists; and produced an efficient infrastructure for identifying, screening, and contacting network members for participation in research.

Potential and challenges of patient-generated health data for high-quality cancer care

Electronic health records and information technology that allow for customizable alerts, intelligent filtering of data, and meaningful aggregation of multiple streams of patient-generated health data with clinical data will be integral to the successful integration of patient-generated health data into routine cancer care.

Incorporating the patient's voice into electronic health records through patient-reported outcomes as the "review of systems"

Owing to lack of standardization for eliciting patient symptoms, the limited time available during clinical encounters, and the often-competing priorities of patients and providers, providers may not appreciate the full spectrum of the patient's symptom experience. Using electronically collected patient-reported outcomes to capture the review of system outside of the clinic visit may not only improve the efficiency, completeness, and accuracy of data collection for the review of system, but also provide the opportunity to operationalize incorporating the patient's voice into the electronic health record. While the necessary technology is already available, multiple stakeholders, including electronic health record vendors, clinicians, researchers, and professional societies, need to align their interests before this can become a widespread reality.

Sex differences in adult outcomes by changes in weight status from adolescence to adulthood: results from Add Health

OBJECTIVE

Changes in weight status from adolescence to adulthood may be associated with varying social, vocational, economic, and educational outcomes, which may differ by sex. We studied whether there are differences in adult outcomes by sex for different weight status changes in the transition to adulthood.

METHODS

Using data from the National Longitudinal Study of Adolescent Health, participants were categorized by weight status from adolescence into adulthood. We examined self-reported outcomes in adulthood for living with parents, being married, being a parent, employment, receipt of public assistance, income, and college graduation by weight groupings (healthy-healthy, healthy-overweight/obese, overweight/obese-overweight/obese, overweight/obese-healthy). The effect of changes in weight status on the adult outcomes was modeled, controlling for sex, age, parental education, and race/ethnicity.

RESULTS

There were differences by sex for many of the self-reported outcomes, especially educational and economic outcomes. Female subjects who became overweight/obese between adolescence and adulthood or remained so had worse economic and educational findings as adults compared to male subjects.

CONCLUSIONS

Overall, for female subjects, becoming and remaining overweight/obese was associated with worse outcomes, while for male subjects, adolescent obesity was more important than isolated adult obesity. The relationship between obesity and life situations may be more negative for female subjects in the transition to adulthood. The findings emphasize that adolescent obesity, and not just obesity isolated in adulthood, is important for characteristics achieved in adulthood.

Accuracy of child and adolescent weight perceptions and their relationships to dieting and exercise behaviors: a NHANES study

OBJECTIVE

Recent public health and media attention on child obesity may have altered accuracy of self-perception of obesity and associated weight control behaviors in children and adolescents. Thus, we examined whether accuracy of weight perceptions were associated with weight loss behaviors.

METHODS

We examined children 8 to 15 years old in the National Health and Nutrition Examination Survey (2005-2010) who reported themselves as "overweight/too fat," "about right," or "underweight/too thin." Children reported on efforts to lose weight and engagement in specific weight control behaviors, including how frequently he or she had been on a diet, starved, cut back on eating, skipped meals, or exercised to lose weight. We categorized obesity on the basis of measured body mass index, and we determined the accuracy of weight perceptions. We used chi-square tests to examine age- and sex-based differences in accuracy of perceptions and relationship to weight loss behaviors.

RESULTS

Girls and older children more accurately perceived weight status. Both girls and boys of all ages who perceived themselves as overweight were more likely to engage in weight loss behaviors. Children who were overweight engaged in more weight loss behaviors than healthy weight children perceiving themselves as overweight. Among children who reported themselves as "about right," overweight children engaged in more weight loss behaviors than healthy weight children but less so than those who accurately perceived themselves as being overweight.

CONCLUSIONS

The perception of being overweight and actual overweight status are both strongly associated with weight loss behaviors. These findings have important implications for counseling patients who may have inaccurate weight perceptions.

Cholesterol curves to identify population norms by age and sex in healthy weight children

OBJECTIVE

Develop clinically applicable charts of lipid values illustrating fluctuations throughout childhood and by sex among healthy weight children.

METHODS

The National Health and Nutrition Examination Survey (1999-2008) was used to estimate total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides by age and sex in healthy weight children age 3 to 17 years. Using LMS procedures, the authors created smoothed curves demonstrating population-based 50th percentile for age and the 75th and 95th percentiles.

RESULTS

The curves were based on 7681 children meeting inclusion criteria. Total cholesterol, HDL, and LDL demonstrated peaks at approximately 8 to 12 years for boys. Similar peaks were evident for girls at slightly younger ages, approximately 7 to 11 years. Triglycerides showed peaks for girls, but values were similar across ages for boys.

CONCLUSIONS

The use of fixed lipid value cutoffs in established guidelines regardless of age or sex likely mislabels many children as abnormal. The authors' charts may allow for a more nuanced interpretation based on population norms.

Physical activity and BMI in a nationally representative sample of children and adolescents

OBJECTIVE

To examine objectively measured physical activity levels by age, sex, and BMI for children and adolescents in a nationally representative sample.

METHODS

Data were from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys, which included physical activity assessment by accelerometer and measured height and weight. The authors calculated minutes of moderate and vigorous activity.

RESULTS

Boys were more active than girls, and activity levels were lower at older ages. Younger children met daily recommendations for physical activity, whereas older children, especially girls, did not. Typically, weight status was inversely related to activity, though differences were less apparent among boys. Underweight children were not always more active than heavier peers.

Differential expression of laminin genes in early chick embryo

The expression patterns of laminin alpha1 and beta1 genes were examined by In situ hybridization of their mRNAs in the early chick embryo from the blastoderm at stage X (morula) to the 10-somite stage. The laminin alpha1 and beta1 transcripts were found in abundance in the chick blastoderm at stage X before initiation of synthesis of the protein. Laminin polypeptides were detected shortly thereafter in embryos at stage XIII (blastula). The expression of the laminin transcripts was intense in the epiblast and in the hypoblast of embryos at stage XIII. During gastrulation (stage HH3-4), the laminin (alpha1 and beta1 cRNAs gave strong signals in the cells ingressing through the primitive streak, in the migrating mesenchymal cells and the cells of the lower layer. The expression of laminin alpha1 and beta1 genes was restricted to specific cell populations later in development. At the neurula stage (stage HH5-6), the expression of laminin transcripts was low in epithelial ectoderm and strong in chordamesoderm neural ectoderm and may implicate important developmental roles for laminin in the morphogenetic movements of neural plate bending during primary neurulation. At the 10-somite stage (stage HH10-11), the (alpha1 and beta1 cRNAs gave no signals in the neural tube, notochord, and ectoderm. The alpha1 and beta1 cRNAs gave strong signals in neural crest cells and this may indicate that the neural crest cells can produce laminin. The alpha1 cRNAs gave strong signals in the dermamyotome and no signal in the sclerotome of somites, and intense signals in the pronephric tubules. The laminin expression pattern in somites may show transient expression of the alpha1 and/or expression of a distinct alpha1 isoform in the sclerotome. The selective expression of laminin alpha1 and beta1 subunits which shows a developmentally regulated, tissue specific distribution suggests potential roles for different members of the same subfamily of genes in the developing chick embryo.

Domain-specific interactions between entactin and neutrophil integrins. G2 domain ligation of integrin alpha3beta1 and E domain ligation of the leukocyte response integrin signal for different responses

Extracellular matrix proteins activate neutrophils to up-regulate many physiologic functions that are necessary at sites of tissue injury. To elucidate the ligand-receptor interactions that mediate these functions, we examined neutrophil activation by the basement membrane protein, entactin. Entactin is structurally and functionally organized into distinct domains; therefore, we utilized glutathione S-transferase -fusion proteins encompassing its four major domains, G1, G2, E, and G3, to assess interactions between entactin and neutrophil integrin receptors. We show that the E domain, which contains the single RGD sequence of entactin, is sufficient for ligation of the beta3-like integrin, leukocyte response integrin, and signaling for chemotaxis. Moreover, the G2 domain signals for stimulation of Fc receptor-mediated phagocytosis via ligation of alpha3beta1. This receptor-ligand interaction was revealed only after stimulation of neutrophil by immune complexes or phorbol esters. Interestingly, the E domain does not enhance phagocytosis, and the G2 domain is not chemotactic. Furthermore, cleavage of entactin with the matrix metalloproteinase, matrilysin, liberates peptides that retain E domain-mediated chemotaxis and G2 domain-mediated enhancement of phagocytosis. These studies indicate that multiple domains of entactin have the ability to ligate individual integrins expressed by neutrophils and to activate distinct functions.

Human trophoblast cell adhesion to extracellular matrix protein, entactin

PROBLEM

Trophoblast interaction with endometrial extracellular matrix (ECM) is crucial during human embryo implantation and placentation. Entactin, a ubiquitous basement membrane glycoprotein, plays a central role in ECM assembly, cell attachment, and chemotaxis. The present study was conducted to examine the possible role of entactin in promoting human trophoblast adhesion.

METHODS

Using an extended life span first trimester trophoblast cell line HTR-8/SVneo (HTR) and a cell adhesion assay, we measured the adherence of human first trimester trophoblasts to recombinant entactin and its domains. Also, we used flow cytometry and indirect immunofluorescence to detect the presence of integrins that may be involved in human trophoblast-entactin interaction; these methods were used to analyze HTR cells, as well as tissue sections and freshly isolated human trophoblasts from first trimester and term placenta.

RESULTS

We found that first trimester trophoblast cells were highly adherent to entactin and its E and G2 domains but not to G1 or G3 domains. Using indirect immunofluorescence and flow cytometry, we found that both beta 1 and beta 3 integrin subunits were expressed on the surface of HTR trophoblast cells adhering to entactin; in contrast, beta 2 and beta 4 integrin subunits were not detected. In addition, we found that alpha v beta 3 was expressed on freshly isolated villous cytotrophoblasts and cytotrophoblast and syncytiotrophoblasts in tissue sections from term placenta. The beta 3 integrin subunit was expressed in cytotrophoblasts and syncytiotrophoblasts in villi of first trimester placental tissue sections.

CONCLUSION

Recombinant entactin promotes human trophoblast cell adhesion through both its E and G2 domains and these specific adhesive interactions may be mediated by beta 1 and/or beta 3 class integrins.

Two distinct cell attachment sites in entactin are revealed by amino acid substitutions and deletion of the RGD sequence in the cysteine-rich epidermal growth factor repeat 2

The basement membrane glycoprotein, entactin, has previously been shown to promote cell attachment and chemotaxis. We have constructed a panel of glutathione S-transferase fusion proteins that encompasses the four major structural domains of entactin, G1, G2, E, and G3. These proteins have been synthesized in bacteria and purified by affinity chromatography. The connecting stalk of entactin, E, which contains four cysteine-rich EGF homology repeats and the integrin receptor RGD recognition sequence, has been modified by deletion of the RGD sequence and substituting glutamic acid for aspartic acid. Attachment assays reveal that the RGD sequence is one of the major cell attachment sites in entactin and that this sequence is recognized by the alpha v beta 3 integrin receptor. Analysis of cell attachment on mutant forms of full-length entactin expressed in the baculovirus expression system revealed a second attachment site that was independent of the RGD sequence. This second site was localized to a peptide of 39 amino acid residues in the second globular G2 domain of entactin. This peptide represents a cysteine-rich EGF repeat. Inhibition of cell attachment by anti-integrin receptor antibodies indicates that the second attachment site is recognized by a member of the beta 1 family of integrin receptors, possibly alpha 3 beta 1.

A novel role for alpha 3 beta 1 integrins in extracellular matrix assembly

To study the biological role of alpha 3 beta 1 integrins in cell adhesion, migration, and in the deposition of extracellular matrix, we stably expressed the human alpha 3 integrin subunit in the alpha 4, alpha 5 integrin deficient CHO cell line B2. The expression of alpha 3 beta 1 integrins enhanced cell adhesion on entactin (also known as nidogen), but not on fibronectin. Using recombinant GST-fusion proteins that span the entire length of the entactin molecule, we located cell adhesive activity to the G2 domain of entactin. These results suggest that the alpha 3 beta 1 integrin functions as an adhesion receptor interacting with the G2 domain of entactin. On the other hand, the expression of alpha 3 beta 1 integrins did not confer the ability to migrate on entactin. Strikingly, the expression of alpha 3 beta 1 dramatically increased the deposition of entactin and fibronectin into the pericellular matrix. This was accompanied by increased binding activity of the 29 kDa amino-terminal domain of fibronectin. Thus, similar to alpha 5 beta 1 integrins, alpha 3 beta 1 integrins can play an important role in modulating the assembly of pericellular matrices. However, unlike fibronectin deposition supported by alpha 5 beta 1, alpha 3 beta 1 supported fibronectin deposition into pericellular matrix was not inhibited by antibodies binding to the RGD containing cell adhesion domain of fibronectin, demonstrating that the two processes are mechanistically distinct. The role of alpha 3 beta 1 in pericellular matrix assembly potentially implicates this receptor in the assembly and/or recognition of entactin-containing pericellular matrices, an observation consistent with its apparent role in the renal glomerulus of the mammalian kidney.

Exon organization of the mouse entactin gene corresponds to the structural domains of the polypeptide and has regional homology to the low-density lipoprotein receptor gene

Entactin is a widespread basement membrane protein of 150 kDa that binds to type IV collagen and laminin. The complete exon-intron structure of the mouse entactin gene has been determined from lambda genomic DNA clones. The gene spans at least 65 kb and contains 20 exons. The exon organization of the mouse entactin gene closely corresponds to the organization of the polypeptide into distinct structural and functional domains. The two amino-terminal globular domains are encoded by three exons each. Single exons encode the two protease-sensitive, O-glycosylated linking regions. The six EGF-like repeats and the single thyroglobulin-type repeat are each encoded by separate exons. The carboxyl-terminal half of entactin displays sequence homology to the growth factor-like region of the low-density lipoprotein receptor, and in both genes this region is encoded by eight exons. The positions of four introns are also conserved in the homologous region of the two genes. These observations suggest that the entactin gene has evolved via exon shuffling. Finally, several sequence polymorphisms useful for gene linkage analysis were found in the 3' noncoding region of the last exon.

Entactin gene expression in normal and fibrotic rat liver and in rat liver cells

BACKGROUND

Entactin, a constituent of basement membranes, is a sulfated glycoprotein with binding sites for laminin, collagen type IV, fibronectin, and cell surfaces. As it is known that excess matrix deposition and sinusoidal basement membrane formation is a central characteristic of liver fibrogenesis, we investigated whether the entactin gene is expressed in normal and in damaged rat liver and which cell types are able to express this gene. In addition, we were interested in the cellular origin and time course of laminin synthesis, a matrix protein closely associated with entactin.

EXPERIMENTAL DESIGN

Entactin gene expression was analyzed in normal, acutely and chronically damaged rat livers (CCl4-model) by immunohistochemistry and in situ detection of specific transcripts. Rat fat-storing cells (FSC) (Ito), hepatocytes, Kupffer cells, liver endothelial cells, arterial smooth muscle cells (SMC), and skin fibroblasts (SF) were isolated according to standard techniques. Entactin gene expression in cultured cells was examined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis of immunoprecipitates, Northern blot analysis, and immunocytochemistry.

RESULTS

In normal liver, entactin was detected in the vessel walls as continuous deposits and in a spot-like fashion along the sinusoids. Entactin was detectable among the cells of the inflammatory infiltrates of acutely damaged liver and in connective tissue septa, in the walls of newly formed vessels and bile ducts of fibrotic liver. Laminin distribution in the vessels was similar, but it was additionally present in the space of Dissé of damaged liver. By in situ hybridization, few entactin-positive cells were found in normal liver sections. Strongly positive cells were scattered over the injured parenchyma of acutely and chronically damaged livers. Northern blot analysis of total RNA extracted from normal and damaged liver tissue showed a distinct increase of entactin specific transcripts during development of fibrosis. Hybridization of total RNA from cultured FSC, hepatocytes, Kupffer cells, endothelial cells, SMC, and SF revealed entactin specific mRNA in FSC, SMC, SF, and endothelial cells; laminin mRNA was found in FSC and SF. Synthesis and secretion of both proteins were found in FSC, SMC and SF. Entactin and laminin gene expression increased in parallel to FSC during time in culture.

CONCLUSIONS

Among the main liver cells, FSC show the highest entactin gene expression and might therefore play the dominant role in the synthesis of this protein in normal and fibrotic liver. However, endothelial cells and liver myofibroblasts could also contribute to entactin production.

The binding of fibronectin to entactin is mediated through the 29 kDa amino terminal fragment of fibronectin and the G2 domain of entactin

Previous work has shown that fibronectin and entactin, an ubiquitous basement membrane glycoprotein, co-localize in the extracellular matrix of the embryonal carcinoma-derived 4CQ cell. Glutathione-S-transferase (GST) fusion proteins containing different domains of entactin have been obtained in the pGEX3X expression vector. These fusion proteins, GST-G1, GST-G2, GST-E and GST-G3, were purified with a glutathione affinity column. By using a solid phase binding assay, it was shown that the 125I-labeled 29 kDa amino terminal fragment of bovine fibronectin bound specifically to the immobilized GST-G2 fusion protein but not to GST-G1, GST-E, and GST-G3. Half saturation for binding of the 29 kDa fibronectin fragment to the immobilized GST-G2 fusion protein was obtained at a concentration of approximately 5 nM. It is suggested that the strong association between GST-G2, which contains the second globular domain of entactin, and the 29 kDa amino terminal fragment of fibronectin may be involved in the assembly of certain types of extracellular matrices.

Migratory interaction of amphibian epidermal cells with components of the basement membrane

In adult newts, basal epidermal cells adjacent to a fresh wound move toward the damaged area by migrating over the epidermal basement membrane. In an attempt to determine which basement membrane components mediate this migration, small pieces of glass coated with various natural matrices, purified proteins, or fragments of proteins were implanted into skin wounds such that epidermal cells attempting to form a wound epithelium would encounter the implants. Laminin derived from a cell line (M1536-B3) that produces no type IV collagen was inactive as a migration substrate. Migration on recombinant entactin was somewhat better than on laminin but was still only approximately 14% of that on type I collagen. M15 matrix, a laminin and entactin-containing product of M1536-B3 cells, was no better than entactin alone. Type IV collagen was an excellent substrate, producing slightly more migration than corresponding concentrations of type I collagen at nearly all concentrations tested. Migration on type IV lacking the NC1 domain was at least as good as on intact type IV. All the activity in type IV was present in a 95 kD fragment (alpha 1(IV)95) from the carboxy terminal two-thirds of the alpha 1 chain. Approximately 60% of the activity on alpha 1(IV)95 was obtained on implants coated with a 110 amino acid fragment of the alpha 1 chain derived from the carboxy terminal half of alpha 1(IV)95. Adding the synthetic peptide, arg-gly-asp-ser (RGDS) to the medium, blocked migration on fibronectin-coated implants but had no effect on implants coated with type IV, suggesting that migration on type IV involves different cell surface receptors than those mediating migration over fibronectin. Matrigel, a commercial product containing most basement membrane components, was a poor migration substrate. Thus if type IV mediates basal cell migration toward a wound in vivo, there may have to be some alterations in basement membrane structure to allow epidermal receptors to access type IV active site(s).

Effects of laminin monoclonal antibodies on the development of cultured rat embryos

Whole rat embryos (9.5 days of gestation) were exposed to six different monoclonal antibodies to laminin during 48 hr of culture. Four (LAM I, LAM V, 5A2, 9D2) of the six were teratogenic or lethal and two (LAM II, 5D3) were not toxic at comparable levels. Teratogenicity and lethality were not related to antibody level, subclass or affinity for whole laminin. Indirect immunofluorescence studies using mouse embryo sections revealed that the toxic antibodies bound in a diffuse manner, while the nontoxic antibodies showed distinct labeling of tissues. These observations suggest that previous varied responses seen in cultured rat embryos exposed to laminin antibodies obtained from humans, monkeys, and rats were the result of differences in the epitope specificity of those antibodies.

Characterization of the 5' end of the mouse Ent gene encoding the basement membrane protein, entactin

Entactin (Ent) is a 150-kDa basement membrane glycoprotein that forms a complex with laminin and also binds to type-IV collagen. For the initial characterization of the 5' end of the mouse Ent gene, we isolated genomic clones that encompass the first three exons of the gene. A 3.5-kb EcoRI fragment at the 5' end of the gene was sequenced and shown to contain 1226 bp of the 5'-flanking DNA, the 260-bp first exon, and 2060 bp of the first intron. The second exon is separated from the first exon by an intron that spans greater than 18 kb. The major transcription start point (tsp) was mapped to 35 nucleotides upstream from the translation start codon. The 5'-flanking DNA contains a putative TATA box, two CAAT boxes and two GC boxes. Nine potential AP-2- and two potential AP-1-binding sites were found in the upstream region and the first intron. The first 248 bp of the promoter region are G+C rich, and they are 65% identical to the promoter of human Ent. Fragments of the 5'-flanking DNA linked to a reporter gene were shown to have promoter activity in transient transfection assays.

Appearance and distribution of entactin in the early chick embryo

Entactin is a sulfated glycoprotein of basement membranes and recent data indicate that it may play a major role in extracellular matrix (ECM) assembly and in modulating the activities of the other molecular components. We investigated the time of appearance and subsequent distribution of entactin during the earliest stages of morphogenesis and its involvement in the first major cellular migrations and interactions in the chick embryo. Entactin is first detected in the epiblast and in the hypoblast at the blastula stage. The accumulating ECM displays intense presence of entactin in the space between the epiblast and the hypoblast at late blastula. Entactin is increasingly abundant in the neural plate and in the ECM and also at least transiently in many mesodermal tissues such as the notochord, the developing heart and somites in the early chick embryo. Immunogold labeling revealed a punctate pattern of entactin distribution in the ECM during the gastrula, neurula and at later stages and at all levels within the embryo. Because of its early appearance in more than one germ layer, entactin may be important in the formation of most embryonic structures. Entactin is detected at the same developmental time and co-localizes with laminin. Antibodies to entactin do not interfere with triggering of the first major cell movements but perturb directional migration of these cells. It would seem that entactin plays a functional role in the directed migration of cells and does not seem to affect cell adhesion during the period of the first morphogenetic events in the early chick embryo.

Recombinant entactin promotes mouse primary trophoblast cell adhesion and migration through the Arg-Gly-Asp (RGD) recognition sequence

In vitro culture of mouse blastocysts during the period coinciding with implantation has revealed that primary trophoblast cells can adhere and migrate in serum-free medium when provided with certain extracellular matrix components, including fibronectin and laminin. Tightly associated with laminin is the glycoprotein, entactin, that may play an important role in basement membrane assembly and cell attachment. Mouse blastocysts were studied using this in vitro model to determine whether entactin was capable of mediating trophoblast invasive activity. Although entactin has never been shown to promote cell migration, we report here that recombinant entactin supported blastocyst outgrowth in a dose-dependent manner, with a maximal effect at 20-50 micrograms/ml. The ability of trophoblast cells to adhere and migrate on entactin was specifically inhibited by anti-entactin antibody, but not by antibodies raised against laminin. The synthetic peptide, Gly-Arg-Gly-Asp-Ser-Pro, that contains the Arg-Gly-Asp (RGD) integrin recognition site, reversibly inhibited entactin-mediated blastocyst outgrowth in a dose-dependent manner, but had no effect on laminin-mediated outgrowth. The synthetic peptide, Gly-Phe-Arg-Gly-Asp-Gly-Gln, that comprises the actual RGD-containing sequence within entactin, promoted trophoblast outgrowth when immobilized on the substratum. Furthermore, a mutated recombinant entactin, altered to contain a Glu in place of Asp at the RGD site, provided no trophoblast cell adhesive activity. We conclude that entactin promotes trophoblast outgrowth through a mechanism mediated by the RGD recognition site, and that it may play an important role during invasion of the endometrial basement membrane at implantation.

Embryonal carcinoma and the basement membrane glycoproteins laminin and entactin

The mouse embryonal carcinoma lines PCC4-F and F9 have played important roles in the isolation and characterization of the two ubiquitous basement membrane proteins, laminin and entactin. The contributions of these cells to our work on extracellular matrices are briefly summarized. The in vitro differentiation of PCC4-F gives rise to a multiplicity of cell types. Two of these cell types have been propagated as cell lines. One of these, M1536-B3, synthesizes and deposits copious quantities of extracellular matrix glycoproteins, which led to the initial discovery and characterization of laminin and entactin. In addition, M1536-B3 provides a model system for analyzing the assembly of laminin and the laminin-entactin complex and for manipulating extracellular matrix structure and composition. The other cell line, 4CQ, synthesizes a matrix consisting of fibronectin and entactin. F9 cells differentiate to endodermal cells in response to retinoic acid and dibutyryl cyclic AMP (Strickland and Mahdavi, Cell 15: 393-402, 1978). The differentiated cells synthesize basement membrane components and provided the probes for the cDNA cloning of entactin and the three chains of laminin. The F9 cells have been widely employed to examine the regulation of expression of the laminin and entactin genes.

Degradation of entactin by matrix metalloproteinases. Susceptibility to matrilysin and identification of cleavage sites

Entactin is the basement membrane protein which bridges laminin and type IV collagen. Entactin is known to be degraded by serine proteinases, but its susceptibility to matrix metalloproteinases has not been determined. We have studied the capacity of three matrix metalloproteinases (interstitial collagenase, 92-kDa gelatinase, and matrilysin) to degrade entactin. While all three metalloenzymes cleaved entactin, matrilysin was approximately 100-fold as effective as collagenase and 600-fold as effective as 92-kDa gelatinase. The Km of matrilysin for entactin was 8.9 x 10(-7) M. A Vmax of 21 molecules of entactin degraded/molecule of matrilysin/min at 37 degrees C was observed. An Arrhenius plot relating matrilysin's catalytic activity to temperature was linear from 15 to 37 degrees C and indicated an activation energy of 10,060 calories/mol. Matrilysin produced multiple, but distinct, cleavages in entactin resulting in peptide fragments ranging from 115 to 29 kDa. The precise sites of cleavage of six fragments were determined by Edman degradation. Cleavage sites consistently occurred amino-terminal to leucine or isoleucine. These data indicate that entactin is a substrate for matrix metalloproteinases. The effectiveness of matrilysin is noteworthy, however, particularly in relation to the minimal ability of other much more well described matrix metalloproteinases to attack this substrate. Our results suggest a potentially important role for matrilysin in disruption of basement membranes by tumor or inflammatory cells.

Biological functions of entactin

Entactin is a sulfated multidomain glycoprotein component of basement membranes. The molecule consists of 1217 amino acids which are organized into two terminal globular domains linked by a rod-like structure largely composed of four EGF- and one thyroglobulin-like cysteine-rich homology repeats. Entactin binds to laminin, collagen IV, fibrinogen, and fibronectin. In the parietal endoderm M1536-B3 cell line, the laminin-entactin complex is formed intracellularly and transported in membrane enclosed vesicles to the extracellular compartment. Transfection of human choriocarcinoma JAR cells, which do not synthesize entactin, with entactin cDNA results in the synthesis and insertion of entactin into the extracellular matrix where it becomes associated with laminin and collagen IV. Indirect immunofluorescent staining also reveals that entactin co-localizes with fibronectin in the extracellular matrix of the embryonal carcinoma-derived 4CQ cell line. These observations suggest that entactin plays an important role in the assembly and properties of diverse extracellular matrices. In addition, entactin binds to immobilized fibrinogen, and more specifically, to the A alpha and B beta chains. The binding of radiolabeled entactin to immobilized fibrinogen is not dependent on metal ions, and is inhibited by antibodies against either fibrinogen or entactin, soluble fibrinogen, and unlabeled entactin. This interaction combined with the chemotactic and phagocytic promoting activities of entactin may be important in hemostasis and would healing.

Entactin stimulates neutrophil adhesion and chemotaxis through interactions between its Arg-Gly-Asp (RGD) domain and the leukocyte response integrin

Entactin is an integral component of basement membranes that plays a major role in basement membrane assembly through its ability to bind avidly to both laminin and type IV collagen. Because neutrophil (PMN) interactions with entactin have not been examined, we investigated the ability of natural and recombinant entactin to mediate PMN adhesion and chemotaxis. With both forms of entactin, we observed that entactin-coated surfaces promoted PMN adhesion and that entactin stimulated PMN chemotaxis. The increase in adhesion to entactin over control was two to threefold whereas the chemotactic response to 15 ng/ml (1 x 10(-10) M) entactin was equivalent to the chemotactic response elicited with 1 x 10(-8) M formyl-methionyl-leucyl-phenylalanine (fMLP). HL-60 cells, after differentiation with dimethylsulfoxide, also demonstrated adhesion and chemotaxis to entactin. A synthetic peptide of the Arg-Gly-Asp (RGD) domain in entactin, SIGFRGDGQTC (S-RGD), mediated PMN adhesion and chemotaxis, and preexposure of PMN to S-RGD blocked PMN adhesion and chemotaxis induced by entactin without diminishing the adhesive and chemotactic activities of fMLP. In contrast, preexposure to peptides SIGFRGEGQTCA or SIGFKGDGQTCA had no effect. The findings with synthetic peptides were confirmed with a recombinant entactin mutant in which aspartic acid at residue 674 was replaced with glutamic acid, thus converting the RGD sequence of entactin to RGE. RGE-entactin was neither adhesive nor chemotactic for neutrophils. Monoclonal antibodies to the leukocyte response integrin (LRI) and the integrin-associated protein blocked entactin-mediated adhesion and chemotaxis whereas monoclonal antibodies to beta 1 and beta 2 integrins had no effect and PMN from an individual with leukocyte-adhesion deficiency adhered normally to entactin-coated surfaces. These data demonstrate that entactin mediates biologically and pathologically important functions of PMN through its RGD domain and that LRI, which has been shown previously to mediate RGD-stimulated phagocytosis, is also capable of mediating RGD-stimulated PMN adhesion and chemotaxis.