Comparative analysis of KRAS4a and KRAS4b splice variants reveals distinctive structural and functional properties

KRAS, the most frequently mutated oncogene in human cancer, produces two isoforms, KRAS4a and KRAS4b, through alternative splicing. These isoforms differ in exon 4, which encodes the final 15 residues of the G-domain and hypervariable regions (HVRs), vital for trafficking and membrane localization. While KRAS4b has been extensively studied, KRAS4a has been largely overlooked. Our multidisciplinary study compared the structural and functional characteristics of KRAS4a and KRAS4b, revealing distinct structural properties and thermal stability. Position 151 influences KRAS4a's thermal stability, while position 153 affects binding to RAF1 CRD protein. Nuclear magnetic resonance analysis identified localized structural differences near sequence variations and provided a solution-state conformational ensemble. Notably, KRAS4a exhibits substantial transcript abundance in bile ducts, liver, and stomach, with transcript levels approaching KRAS4b in the colon and rectum. Functional disparities were observed in full-length KRAS variants, highlighting the impact of HVR variations on interaction with trafficking proteins and downstream effectors like RAF and PI3K within cells.

High-Throughput Cell-Based Screening of Small Molecule KRAS Signaling Inhibitors Using a Homogeneous Time-Resolved Fluorescence (HTRF) Assay

With recent advances proving that effective inhibition of KRAS is possible, there have been significant efforts made to develop inhibitors of specific mutant alleles. Here we describe a detailed protocol that employs homogeneous time-resolved fluorescence (HTRF) to identify compounds acting on KRAS signaling in malignant cell lines. This method allows for high-throughput, cell-based screens of large compound libraries for the development of RAS-targeted therapeutics.

Prevalence of epitheliocystis in freshwater Atlantic salmon reared in flow-through and recirculation aquaculture systems

Epitheliocystis, an intracellular bacterial infection in the gills and skin epithelium, has been frequently reported in Atlantic salmon (Salmo salar) during freshwater production in a number of countries. This study describes the prevalence and intensity of a natural epitheliocystis infection present in the gills of two strains of Atlantic salmon reared in either a flow-through (FT) or a recirculation aquaculture system (RAS) in Ireland. Repeated sampling of gills prior to and throughout seawater transfer, histology and quantitative real-time PCR were used to determine infection prevalence and intensity. Despite no clinical gill disease, and minor histopathological changes, epitheliocystis lesions were identified in histology at all time points. Specific PCR confirmed the presence of Candidatus Clavichlamydia salmonicola in both strains and its number of copies was correlated with intensity of epitheliocystis lesions. A significant interaction between hatchery system and fish strain on the prevalence and intensity of gill epitheliocystis was found both using histological and molecular methods. Specifically, fish from FT had higher prevalence and intensity than RAS reared fish and within FT, the Irish cohort were more affected than Icelandic.

Virtual screening for small-molecule pathway regulators by image-profile matching

Identifying the chemical regulators of biological pathways is a time-consuming bottleneck in developing therapeutics and research compounds. Typically, thousands to millions of candidate small molecules are tested in target-based biochemical screens or phenotypic cell-based screens, both expensive experiments customized to each disease. Here, our uncustomized, virtual, profile-based screening approach instead identifies compounds that match to pathways based on the phenotypic information in public cell image data, created using the Cell Painting assay. Our straightforward correlation-based computational strategy retrospectively uncovered the expected, known small-molecule regulators for 32% of positive-control gene queries. In prospective, discovery mode, we efficiently identified new compounds related to three query genes and validated them in subsequent gene-relevant assays, including compounds that phenocopy or pheno-oppose YAP1 overexpression and kill a Yap1-dependent sarcoma cell line. This image-profile-based approach could replace many customized labor- and resource-intensive screens and accelerate the discovery of biologically and therapeutically useful compounds.

The pericranial flap for inner lining of full-thickness nasal defects: a retrospective cohort study

BACKGROUND

Effective nasal reconstruction requires skin and soft tissue cover, cartilage or bone structure, and mucosal lining. Ideal lining is thin, pliable and vascularised, making reconstruction challenging. This paper presents the first case series with long-term outcomes of pericranial flaps used as inner lining for nasal reconstruction.

METHODS

Patients undergoing paramedial forehead flaps from 2007 to 2019 were identified using second-stage nasal reconstruction billing codes. Patients with pericranial flaps for lining, for whom there were data on resulting outcomes and complications, were identified.

RESULTS

Sixty-six patients underwent second-stage nasal reconstruction. Eighteen patients had paramedian forehead and pericranial flaps for inner lining reconstruction. The flap lining had no immediate post-operative complications. Three patients suffered partial to major reconstructive failure post radiotherapy. Other complications included nasal stenosis and orocutaneous fistula.

CONCLUSION

Combined with paramedian forehead flaps, the pericranial flap is reliable as inner lining for nasal reconstruction. It is easily accessible and useful in resections with limited mucosal options.

Abstract 2272: Interrogating RAS isoform and mutational specificity for effectors with bioluminescence resonance energy transfer (BRET)

Mutations in the small GTPases HRAS, NRAS, and splice variants KRAS4a and KRAS4b occur in roughly 20% of all cancers1. Each of these four RAS isoforms share a high degree of homology, yet play distinct biological roles; mouse models devoid of KRAS die mid-gestation, whereas HRAS and NRAS null mice survive2. The occurrence of RAS isoform mutations and their specific oncogenic codon substitutions are non-uniform across cancer types, with KRAS mutations in the G12 position frequently driving colorectal cancer while NRAS Q61 mutations are commonly present in skin cancer1. Several explanations have been proposed for this, including differential regulation at the level of transcription, mRNA stability, translation, and protein stability, along with distinctions in post-translational modification, localization, and tissue-specific availability of effectors3. Subtle differences in the biochemical properties of amino acid substitutions may also influence the dominant mutational forms across cancer types. However, the question of whether RAS isoforms and their specific codon substitutions preferentially engage with certain effectors within a cellular context remains unclear, despite considerable efforts. Here, we utilize bioluminescence resonance energy transfer (BRET) between mVenus- and NanoLuc-tagged recombinant proteins to derive quantitative measurements of effector affinity across RAS isoforms and common mutants. By transiently expressing a fixed concentration of NanoLuc-tagged effectors while titrating increasing amounts of mVenus-tagged RAS in a cellular system, we generated saturation curves that reflect the nature of binding between the protein pair in vivo to help untangle this longstanding question. We further validated interactions by immunoprecipitation, and determined construct expression and colocalization via western blot and confocal microscopy.

1Prior IA, Hood FE, Hartley JL. The frequency of Ras mutations in cancer. Cancer Research 20202Malumbres M, Barbacid M. RAS oncogenes: the first 30 years. Nature Reviews Cancer 2003;3:459-653Li S, Balmain A, Counter CM. A model for RAS mutation patterns in cancers: finding the sweet spot. Nature Reviews Cancer 2018;18:767-77

Citation Format: Megan Rigby, John Columbus, Vanessa Wall, Dominic Esposito, Thomas Turbyville. Interrogating RAS isoform and mutational specificity for effectors with bioluminescence resonance energy transfer (BRET) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2272.

The Effect of Antimicrobial Treatment upon the Gill Bacteriome of Atlantic Salmon (Salmo salar L.) and Progression of Amoebic Gill Disease (AGD) In Vivo

Branchial surfaces of finfish species contain a microbial layer rich in commensal bacteria which can provide protection through competitive colonization and production of antimicrobial products. Upon disturbance or compromise, pathogenic microbiota may opportunistically infiltrate this protective barrier and initiate disease. Amoebic gill disease (AGD) is a globally significant health condition affecting salmonid mariculture. The current study examined whether altering the diversity and/or abundance of branchial bacteria could influence the development of experimentally induced AGD. Here, we challenged Atlantic salmon (Salmo salar) with Neoparamoeba perurans in a number of scenarios where the bacterial community on the gill was altered or in a state of instability. Administration of oxytetracycline (in-feed) and chloramine-T (immersion bath) significantly altered the bacterial load and diversity of bacterial taxa upon the gill surface, and shifted the community profile appreciably. AGD severity was marginally higher in fish previously subjected to chloramine-T treatment following 21 days post-challenge. This research suggests that AGD progression and severity was not clearly linked to specific bacterial taxa present in these systems. However, we identified AGD associated taxa including known pathogenic genus (Aliivibrio, Tenacibaculum and Pseudomonas) which increased in abundance as AGD progressed. Elucidation of a potential role for these bacterial taxa in AGD development is warranted.

Evaluation of the Infectious Potential of Neoparamoeba perurans Following Freshwater Bathing Treatments

Freshwater bathing for 2–3 h is the main treatment to control amoebic gill disease of marine-farmed Atlantic salmon. Recent in vitro studies have demonstrated that amoebae (Neoparamoeba perurans) detach when exposed to freshwater and that some eventually reattach to culture plates when returned to seawater. Here, we evaluated the potential for gill-detached N. perurans to survive a commercially relevant treatment and infect AGD-naïve fish and whether holding used bathwater for up to 6 h post treatment would lower infectivity. AGD-affected fish were bathed in freshwater for 2 h. Naïve salmon were exposed to aliquots of the used bathwater after 2, 4, 6 and 8 h. The inoculation was performed at 30 ppt for 2 h, followed by gradual dilution with seawater. Sampling at 20 days post inoculation (dpi) and 40 dpi confirmed rapid AGD development in fish inoculated in 2 h used bathwater, but a slower AGD development following exposure to 4 h bathwater. AGD signs were variable and reduced following longer bathwater holding times. These results suggest that viable amoebae are likely returned to seawater following commercial freshwater treatments, but that the risk of infection can be reduced by retention of bathwater before release.

Seawater transmission and infection dynamics of pilchard orthomyxovirus (POMV) in Atlantic salmon (Salmo salar)

The Tasmanian salmon industry had remained relatively free of major viral diseases until the emergence of pilchard orthomyxovirus (POMV). Originally isolated from wild pilchards, POMV is of concern to the industry as it can cause high mortality in farmed salmon (Salmo salar). Field observations suggest the virus can spread from pen to pen and between farms, but evidence of passive transmission in sea water was unclear. Our aim was to establish whether direct contact between infected and naïve fish was required for transmission, and to examine viral infection dynamics. Atlantic salmon post-smolts were challenged with POMV by either direct exposure via cohabitation or indirect exposure via virus-contaminated sea water. POMV was transmissible in sea water and direct contact between fish was not required for infection. Head kidney and heart presented the highest viral loads in early stages of infection. POMV survivors presented low viral loads in most tissues, but these remained relatively high in gills. A consistent feature was the infiltration of viral-infected melanomacrophages in different tissues, suggesting an important role of these in the immune response to POMV. Understanding POMV transmission and host-pathogen interactions is key for the development of improved surveillance tools, transmission models and ultimately for disease prevention.

RAS internal tandem duplication disrupts GTPase-activating protein (GAP) binding to activate oncogenic signaling

The oncogene RAS is one of the most widely studied proteins in cancer biology, and mutant active RAS is a driver in many types of solid tumors and hematological malignancies. Yet the biological effects of different RAS mutations and the tissue-specific clinical implications are complex and nuanced. Here, we identified an internal tandem duplication (ITD) in the switch II domain of NRAS from a patient with extremely aggressive colorectal carcinoma. Results of whole-exome DNA sequencing of primary and metastatic tumors indicated that this mutation was present in all analyzed metastases and excluded the presence of any other clear oncogenic driver mutations. Biochemical analysis revealed increased interaction of the RAS ITD with Raf proto-oncogene Ser/Thr kinase (RAF), leading to increased phosphorylation of downstream MAPK/ERK kinase (MEK)/extracellular signal-regulated kinase (ERK). The ITD prevented interaction with neurofibromin 1 (NF1)-GTPase-activating protein (GAP), providing a mechanism for sustained activity of the RAS ITD protein. We present the first crystal structures of NRAS and KRAS ITD at 1.65-1.75 Å resolution, respectively, providing insight into the physical interactions of this class of RAS variants with its regulatory and effector proteins. Our in-depth bedside-to-bench analysis uncovers the molecular mechanism underlying a case of highly aggressive colorectal cancer and illustrates the importance of robust biochemical and biophysical approaches in the implementation of individualized medicine.

Membrane interactions of the globular domain and the hypervariable region of KRAS4b define its unique diffusion behavior

The RAS proteins are GTP-dependent switches that regulate signaling pathways and are frequently mutated in cancer. RAS proteins concentrate in the plasma membrane via lipid-tethers and hypervariable region side-chain interactions in distinct nano-domains. However, little is known about RAS membrane dynamics and the details of RAS activation of downstream signaling. Here, we characterize RAS in live human and mouse cells using single-molecule-tracking methods and estimate RAS mobility parameters. KRAS4b exhibits confined mobility with three diffusive states distinct from the other RAS isoforms (KRAS4a, NRAS, and HRAS); and although most of the amino acid differences between RAS isoforms lie within the hypervariable region, the additional confinement of KRAS4b is largely determined by the protein’s globular domain. To understand the altered mobility of an oncogenic KRAS4b, we used complementary experimental and molecular dynamics simulation approaches to reveal a detailed mechanism.

The interaction between temperature and dose on the efficacy and biochemical response of Atlantic salmon to hydrogen peroxide treatment for amoebic gill disease

Hydrogen peroxide (H₂ O₂ ) is a commonly used treatment for a range of parasitic diseases of marine finfish, including amoebic gill disease (AGD). While this treatment is partially effective at reducing parasite load, H₂ O₂ can have detrimental effects on the host under certain conditions. Treatment temperature and dose concentration are two factors that are known to influence the toxicity of H₂ O₂ ; however, their impact on the outcome of AGD treatment remains unclear. Here, we investigated the effects of treatment temperature (8, 12 or 16°C) and dose concentration (750, 1,000, 1,250 mg/L) on the efficacy of H₂ O₂ to treat AGD. We demonstrated that a 20-min bath treatment of H₂ O₂ at all doses reduced both parasite load and gross gill score significantly. Parasite load and gross gill score were lowest in the 1,000 mg/L treatment performed at 12°C. At the high dose and temperature combinations, H₂ O₂ caused moderate gill damage and a significant increase in the plasma concentration of electrolytes (sodium, chloride and potassium). Taken together, our study demonstrates that higher H₂ O₂ treatment temperatures can adversely affect the host and do not improve the effectiveness of the treatment.

P1598 Ruptured Sinus of Valsalva: clinical and echocardiographic features at presentation and long-term results after surgical and percutaneous repair

Background

Rupture of Sinus of Valsalva (rSOV) is a rare and potentially life-threatening condition often misdiagnosed. Percutaneous device closure has been replacing surgical repair as a treatment of choice. However, long-term outcome is poorly documented.

Methods

Echo database (2001-2019) was searched for patients >16y with rSOV. Clinical data were collected from ACHD database. Marfan Syndrome patients were excluded.

Results

Fifteen patients (42.2y, 10M) were diagnosed with rSOVbetween 1979 and 2019. HF symptoms at initial presentation were reported in 50%. All cases were diagnosed by TTE with finding of high velocity continuous flow from SOV to right heart. Two were initially misdiagnosed as VSD. Digital imaging recordings of 10/15 were available. The aortic root was dilated in 8/10. Four had asymmetrical SOV dilatation. LV and LA were dilated in 7/10 and 9/10. Significant aortic regurgitation was in 4. Two had RVOTO. RVSP was always raised. Echo findings are summarised in the Table.

Mean FU after repair was 10,7y (0,9-39). Ten patients had surgical repair and 5 device closure. Seven had repair of concomitant lesions (4 VSD closure and 3 AVR) at the time of the procedure. One redo device closure was performed. During FU 1 died from Cardiomyopathy. At the latest FU significant improvement in functional class, LV and LA size and RVSP was found.

Conclusion

Patients with rSOV may present with acute HF. High velocity continuous flow from SOV to right heart on TTE is characteristic feature for diagnosis. Percutaneous closure is an attractive alternative to surgery in patients with isolated lesion. Significant haemodynamic improvement can be achieved with good long-term haemodynamic results

Tot = 15 Initial findings Latest FU NYHA class 4 class I 2 class II 2 class III 4 class IV 3 unknown 11 class I 2 class II 1 class III 0 class IV* SOV (mm) 38.2 (33-44) STJ (mm) 36.2 (26-42 Asc Ao (mm) 30.3 (25-34) rupture site 8 RC sinus, 2 NC sinus Shunt to 8 RVOT, 1 RA, 1 RVOT + RA LVEDV (ml) 169.7 (114-330) 120 (67-230)* LVESV (ml) 66(42-130) 46 (28-80)* LAVi (ml/m2) 53.1 (30-129) 35 (24-53)* LV EF% 61.2 (57-65) 60.4 (50-70) RVSP (mmHg) 53.2 (37-130) 24.06 (15-32)** Pre VS post procedure p-value: * P < 0,05 **P < 0,01

Abstract P1598 Figure. PLAX in patient with ruptured RC sinus

Organization and content of primary care for adolescents – comparison of actual and desired situation

To successfully navigate increasing autonomy, independence and health behaviors in adolescence, accessible adolescent health care services (AHS) are essential. AHS comprise all services in primary care that are aimed at the specific needs of adolescents and can be provided in various settings such as public services, private services, schools and hospitals. In the MOCHA project (Models of Child Health Appraised) we assessed the structure and content of AHS in 30 European countries against the standards in the field of adolescent health services: accessibility, staff attitude, communication, staff competency and skills, confidential and continuous care, age appropriate environment, involvement in health care, equity and respect and a strong link with the community. The results revealed that although half of the 30 countries did adopt adolescent-specific policies, many countries did not meet the current standards of quality health care for adolescents. For example, the ability to provide emergency mental health care is limited. In addition, one third of the countries do not have a formal policy which guarantees the confidentiality of a consult and the possibility to consult a physician without parents knowing. Finally, around half of the countries do not have specialized centers in adolescent health care in order to tackle comprehensive health issues. Access to adolescent health care services needs to be improved for vulnerable adolescents such as migrant adolescents. Schools, ambulatory settings and hospitals should offer accessible, comprehensive health care and a culturally appropriate approach, particularly given the number of migrant adolescents living in EU and EEA countries. Finally, the health care systems should improve their communication strategies, to assist young people in understanding their rights and responsibility in the domain of health, and how and where to access to adequate care.

Detection and verification of 2.3 million cancer mutations in NCI60 cancer cell lines with a cloud search engine

Today we have unprecedented access to human genomic and proteomic data that appear to be rapidly approaching our current understanding of comprehensive coverage. Combining genomic information with shotgun proteomics remains challenging due to the large increase in proteomics search space. However, making this connection between genomic and proteomic information is critical for cancer studies to vaccine development. Furthermore, as we progress towards personalized medicine, it will be essential for proteomics analysis to identify individual mutations and variants in order to fully understand protein networks and to develop personalized therapies. While these advantages are well-established, only a few studies have demonstrated the successful integration of proteomic data with large genomic input. We present and examine the abilities of Bolt, a new cloud-based proteomics search engine to search for the presence of over 2.3 million known cancer mutations in a matter of minutes while still performing a standard proteomics search that includes 31 post translational modifications. We use previously published proteomics data sets and identify mutations that are verified using genomic studies as well as previous proteomics efforts. Our results also emphasize the need to search for mutations in a comprehensive manner while still searching for both common and rare PTMs. SIGNIFICANCE: We present and examine the abilities of Bolt, a new cloud-based proteomics search engine to search for the presence of over 2.3 million known cancer mutations in a matter of minutes while still performing a standard proteomics search that includes 31 post translational modifications. No other proteomics search software can do so.

Increase in CFC-11 emissions from eastern China based on atmospheric observations

The recovery of the stratospheric ozone layer relies on the continued decline in the atmospheric concentrations of ozone-depleting gases such as chlorofluorocarbons¹. The atmospheric concentration of trichlorofluoromethane (CFC-11), the second-most abundant chlorofluorocarbon, has declined substantially since the mid-1990s². A recently reported slowdown in the decline of the atmospheric concentration of CFC-11 after 2012, however, suggests that global emissions have increased^3,4. A concurrent increase in CFC-11 emissions from eastern Asia contributes to the global emission increase, but the location and magnitude of this regional source are unknown³. Here, using high-frequency atmospheric observations from Gosan, South Korea, and Hateruma, Japan, together with global monitoring data and atmospheric chemical transport model simulations, we investigate regional CFC-11 emissions from eastern Asia. We show that emissions from eastern mainland China are 7.0 ± 3.0 (±1 standard deviation) gigagrams per year higher in 2014-2017 than in 2008-2012, and that the increase in emissions arises primarily around the northeastern provinces of Shandong and Hebei. This increase accounts for a substantial fraction (at least 40 to 60 per cent) of the global rise in CFC-11 emissions. We find no evidence for a significant increase in CFC-11 emissions from any other eastern Asian countries or other regions of the world where there are available data for the detection of regional emissions. The attribution of any remaining fraction of the global CFC-11 emission rise to other regions is limited by the sparsity of long-term measurements of sufficient frequency near potentially emissive regions. Several considerations suggest that the increase in CFC-11 emissions from eastern mainland China is likely to be the result of new production and use, which is inconsistent with the Montreal Protocol agreement to phase out global chlorofluorocarbon production by 2010.

Continued Emissions of the Ozone-Depleting Substance Carbon Tetrachloride From Eastern Asia

Carbon tetrachloride (CCl₄) is an ozone-depleting substance, accounting for about 10% of the chlorine in the troposphere. Under the terms of the Montreal Protocol, its production for dispersive uses was banned from 2010. In this work we show that, despite the controls on production being introduced, CCl₄ emissions from the eastern part of China did not decline between 2009 and 2016. This finding is in contrast to a recent bottom-up estimate, which predicted a significant decrease in emissions after the introduction of production controls. We find eastern Asian emissions of CCl₄ to be 16 (9-24) Gg/year on average between 2009 and 2016, with the primary source regions being in eastern China. The spatial distribution of emissions that we derive suggests that the source distribution of CCl₄ in China changed during the 8-year study period, indicating a new source or sources of emissions from China's Shandong province after 2012.

Health Informatics 3.0 and other Increasingly Dispersed Technologies Require Even Greater Trust: Promoting Safe Evidence-based Health Informatics

Healthinformaticsisgenerallylesscommittedtoascientific evidence-basedapproach than any other area of health science, which is an unsound position. Introducing the new Web 3.0 paradigms into health IT applications can unleash a further great potential, able to integrate and distribute data from multiple sources. The counter sideisthatitmakestheuserandthepatientevermoredependentonthe

‘blackbox’ of the system, and the re-use of the data remote from the author and initial context. Thus anticipatory consideration of uses, and proactive analysis of evidenceof effects,are imperative,as only when a clinical technology can be proven to be trustworthy and safe should it be implementedwidely as is the case with other health technologies.

Toargueforpromotingevidence-basedhealthinformatics assystemsbecomemorepowerfulandpro-activeyetmoredispersed andremote;andevaluationasthemeansofgeneratingthenecessaryscientific evidencebase.TopresentongoingIMIAandEFMIinitiativesinthisfield.

Critical overview of recent developments in health informatics evaluation, alongside the precedents of other health technologies, summarising current initiatives and the new challenges presented by Health Informatics 3.0.

Web3.0should betaken asanopportunitytomovehealth informatics from being largely unaccountable to one of being an ethical andresponsiblescience-baseddomain.Recentandplannedactivities ofthe EFMIandIMIAworkinggroupshavesignificantlyprogressedkeyinitiatives.

Concurrent with the emergence of Web 3.0 as a means of new-generation diffuse health information systems comes an increasing need for an evidence-based culture in health informatics.

Evidence Based Health Informatics: 10 Years of Efforts to Promote the Principle

Objectives: To present the importance of Evidence-based Health Informatics (EBHI) and the ethical imperative of this approach; to highlight the work of the IMIA Working Group on Technology Assessment and Quality Improvement and the EFMI Working Group on Assessment of Health Information Systems; and to introduce the further important evaluation and evidence aspects being addressed.

Methods: Reviews of IMIA, EFMA and other initiatives, together with literature reviews on evaluation methods and on published systematic reviews.

Results: Presentation of the rationale for the health informatics domain to adopt a scientific approach by assessing impact, avoiding harm, and empirically demonstrating benefit and best use; reporting of the origins and rationale of the IMIA- and EQUATOR-endorsed Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI) and of the IMIA WG's Guideline for Good Evaluation Practice in Health Informatics (GEP-HI); presentation of other initiatives for objective evaluation; and outlining of further work in hand on usability and indicators; together with the case for development of relevant evaluation methods in newer applications such as telemedicine. The focus is on scientific evaluation as a reliable source of evidence, and on structured presentation of results to enable easy retrieval of evidence.

Conclusions: EBHI is feasible, necessary for efficiency and safety, and ethically essential. Given the significant impact of health informatics on health systems, care delivery and personal health, it is vital that cultures change to insist on evidence-based policies and investment, and that emergent global moves for this are supported.

Finding Ethical Principles and Practical Guidelines for the Controlled Flow of Patient Data

The application of computing to health care, and particularly to electronic patient records, offers major benefits but raises issues of confidentiality and of potential misuse. Sound access control mechanisms are therefore important, but most models focus upon informed consent by the data subject. This raises challenges in mental health care, and for other vulnerable patients including those comatose, and the severely ill and temporarily distressed. Published algorithms which are used to control record access within a controlled environment therefore have value, as a means of ensuring an open and informed, yet ethically sound, solution. The paper describes the background and issues, and gives an example of such an algorithm.

Systematic Prioritization of the STARE-HI Reporting Items

Background: We previously devised and published a guideline for reporting health informatics evaluation studies named STARE-HI, which is formally endorsed by IMIA and EFMI.

Objective: To develop a prioritization framework of ranked reporting items to assist authors when reporting health informatics evaluation studies in space restricted conference papers and to apply this prioritization framework to measure the quality of recent health informatics conference papers on evaluation studies.

Method: We deconstructed the STARE-HI guideline to identify reporting items. We invited a total of 111 authors of health informatics evaluation studies, reviewers and editors of health Informatics conference proceedings to score those reporting items on a scale ranging from “0 – not necessary in a conference paper” through to “10 – essential in a conference paper” by a web-based survey. From the responses we derived a mean priority score. All evaluation papers published in proceedings of MIE2006, Medinfo2007, MIE2008 and AMIA2008 were rated on these items by two reviewers. From these ratings a priority adjusted completeness score was computed for each paper.

Results: We identified 104 reporting items from the STARE-HI guideline. The response rate for the survey was 59% (66 out of 111). The most important reporting items (mean score ≥ 9) were “Interpret the data and give an answer to the study question – (in Discussion)”, “Whether it is a laboratory, simulation or field study – (in Methods-study design)” and “Description of the outcome measure/evaluation criteria – (in Methods-study design)”. Per reporting area the statistically more significant important reporting items were distinguished from less important ones. Four reporting items had a mean score ≤ 6. The mean priority adjusted completeness of evaluation papers of recent health informatics conferences was 48% (range 14 –78%).

Conclusion: We produced a ranked list of reporting items from STARE-HI according to their prioritized relevance for inclusion in space-limited conference papers. The priority adjusted completeness scores demonstrated room for improvement for the analyzed conference papers. We believe that this prioritization framework is an aid to improving the quality and utility of conference papers on health informatics evaluation studies.

Evaluation Considerations for Secondary Uses of Clinical Data: Principles for an Evidence-based Approach to Policy and Implementation of Secondary Analysis

Objectives: To set the scientific context and then suggest principles for an evidence-based approach to secondary uses of clinical data, covering both evaluation of the secondary uses of data and evaluation of health systems and services based upon secondary uses of data. Method: Working Group review of selected literature and policy approaches. Results: We present important considerations in the evaluation of secondary uses of clinical data from the angles of governance and trust, theory, semantics, and policy. We make the case for a multi-level and multi-factorial approach to the evaluation of secondary uses of clinical data and describe a methodological framework for best practice. We emphasise the importance of evaluating the governance of secondary uses of health data in maintaining trust, which is essential for such uses. We also offer examples of the re-use of routine health data to demonstrate how it can support evaluation of clinical performance and optimize health IT system design. Conclusions: Great expectations are resting upon "Big Data" and innovative analytics. However, to build and maintain public trust, improve data reliability, and assure the validity of analytic inferences, there must be independent and transparent evaluation. A mature and evidence-based approach needs not merely data science, but must be guided by the broader concerns of applied health informatics.

Behavioural adjustments of wild-caught kangaroos to captivity

It is important to understand how wild-caught animals may respond to captivity, and whether their behaviours in captivity are reflective of their wild counterparts. We observed the behaviour of wild-caught western grey kangaroos (Macropus fuliginosus) and red kangaroos (Osphranter rufus; formerly M. rufus) that were transferred to a large naturally vegetated enclosure. Observations were made on the first day of captivity and again after 7–10 days, and were compared with the behaviour of free-living kangaroos at the same locality and over the same period. We quantified feeding, moving, grooming and non-alert behaviours. Of these, grooming was higher in captive kangaroos than in free-living animals on the first day of captivity only, and was no different to that of wild animal by 7–10 days’ captivity. Such self-directed behaviour may be indicative of heightened distress for kangaroos on the first day of captivity, but it may also be indicative of grooming to eliminate contamination of human smells or debris following capture by darting and recovery. Overall, our findings indicate that after a short period of captivity, wild-caught kangaroos adjust to a novel environment relatively quickly, and animals from each species showed behaviour patterns comparable with free-ranging counterparts within 7–10 days after capture and captivity.

Improving Evaluation to Address the Unintended Consequences of Health Information Technology:. a Position Paper from the Working Group on Technology Assessment & Quality Development

BACKGROUND AND OBJECTIVES

With growing use of IT by healthcare professionals and patients, the opportunity for any unintended effects of technology to disrupt care health processes and outcomes is intensified. The objectives of this position paper by the IMIA Working Group (WG) on Technology Assessment and Quality Development are to highlight how our ongoing initiatives to enhance evaluation are also addressing the unintended consequences of health IT.

METHODS

Review of WG initiatives Results: We argue that an evidence-based approach underpinned by rigorous evaluation is fundamental to the safe and effective use of IT, and for detecting and addressing its unintended consequences in a timely manner. We provide an overview of our ongoing initiatives to strengthen study design, execution and reporting by using evaluation frameworks and guidelines which can enable better characterization and monitoring of unintended consequences, including the Good Evaluation Practice Guideline in Health Informatics (GEP-HI) and the Statement on Reporting of Evaluation Studies in Health Informatics (STARE-HI). Indicators to benchmark the adoption and impact of IT can similarly be used to monitor unintended effects on healthcare structures, processes and outcome. We have also developed EvalDB, a web-based database of evaluation studies to promulgate evidence about unintended effects and are developing the content for courses to improve training in health IT evaluation.

CONCLUSION

Evaluation is an essential ingredient for the effective use of IT to improve healthcare quality and patient safety. WG resources and skills development initiatives can facilitate a proactive and evidence-based approach to detecting and addressing the unintended effects of health IT.

Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis

BACKGROUND

In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps.

METHODS

Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution.

RESULTS

Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group.

CONCLUSIONS

We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.

Optimising Health Informatics Outcomes--Getting Good Evidence to Where it Matters

This editorial is part of a For-Discussion-Section of Methods of Information in Medicine about the paper "Evidence-based Health informatics: How do we know what we know?", written by Elske Ammenwerth [1]. Health informatics uses and applications have crept up on health systems over half a century, starting as simple automation of large-scale calculations, but now manifesting in many cases as rule- and algorithm-based creation of composite clinical analyses and 'black box' computation of clinical aspects, as well as enablement of increasingly complex care delivery modes and consumer health access. In this process health informatics has very largely bypassed the rules of precaution, proof of effectiveness, and assessment of safety applicable to all other health sciences and clinical support systems. Evaluation of informatics applications, compilation and recognition of the importance of evidence, and normalisation of Evidence Based Health Informatics, are now long overdue on grounds of efficiency and safety. Ammenwerth has now produced a rigorous analysis of the current position on evidence, and evaluation as its lifeblood, which demands careful study then active promulgation. Decisions based on political aspirations, 'modernisation' hopes, and unsupported commercial claims must cease - poor decisions are wasteful and bad systems can kill. Evidence Based Health Informatics should be promoted, and expected by users, as rigorously as Cochrane promoted Effectiveness and Efficiency, and Sackett promoted Evidence Based Medicine - both of which also were introduced retrospectively to challenge the less robust and partially unsafe traditional 'wisdom' in vogue. Ammenwerth's analysis gives the necessary material to promote that mission.

Patient Portals as a Means of Information and Communication Technology Support to Patient- Centric Care Coordination - the Missing Evidence and the Challenges of Evaluation. A joint contribution of IMIA WG EVAL and EFMI WG EVAL

OBJECTIVES

To review the potential contribution of Information and Communication Technology (ICT) to enable patient-centric and coordinated care, and in particular to explore the role of patient portals as a developing ICT tool, to assess the available evidence, and to describe the evaluation challenges.

METHODS

Reviews of IMIA, EFMI, and other initiatives, together with literature reviews.

RESULTS

We present the progression from care coordination to care integration, and from patient-centric to person-centric approaches. We describe the different roles of ICT as an enabler of the effective presentation of information as and when needed. We focus on the patient's role as a co-producer of health as well as the focus and purpose of care. We discuss the need for changing organisational processes as well as the current mixed evidence regarding patient portals as a logical tool, and the reasons for this dichotomy, together with the evaluation principles supported by theoretical frameworks so as to yield robust evidence.

CONCLUSIONS

There is expressed commitment to coordinated care and to putting the patient in the centre. However to achieve this, new interactive patient portals will be needed to enable peer communication by all stakeholders including patients and professionals. Few portals capable of this exist to date. The evaluation of these portals as enablers of system change, rather than as simple windows into electronic records, is at an early stage and novel evaluation approaches are needed.

Citation analysis in health care sciences. Innovative investigation or seductive pseudo-science?

BACKGROUND

Citations of scientific papers in health care have become a subject of interest, as in any scientific sector. However, such a metric, while useful in a simple way, can become subject to too much credibility, and therefore to advanced analyses which are not soundly grounded even if methodologically valid.

OBJECTIVES

The objective was to contextualise citation indices in health care science, juxtaposed with a parallel analytic paper.

METHODS

The literature was reviewed and set against the objectives of metrics of literature and of researchers.

RESULTS

The strengths and weaknesses of citation indices in the health sector were identified, with practical examples of perverse effects, and compared with the core objectives of health care development.

CONCLUSIONS

Citation indices in health care science have a value, but this is limited to giving a broad overview. Other measures of effectiveness, including impact on education, on health care development, and on stimulation of applied developments, are needed rather than spuriously scientific advanced analyses of citation counts.

The RICHE taxonomy - an innovative means of classification of child health research

BACKGROUND

Research outputs increase inexorably. Health is now a required element in all policies of the European Union. There is a need for a system that helps to navigate the vast body of children's health research, identify pertinent research institutions, discover ongoing and recently funded research projects and identify gaps where there is little knowledge.

METHODS

The European Commission funded the Research Inventory of Child Health in Europe (RICHE) project through the Framework 7 Programme, to identify gaps in child health research in Europe. A necessary first step was to identify and index current research, for which a website repository was created. As a basis for this task, an innovative taxonomy was necessary to encompass the many arenas of children's health and development, including subjects outside the traditional areas of children's health. Drawing inspiration from existing taxonomies, library systems and other forms of classification, a multi-axial approach was selected as the best way to encompass the many influences on children's health. Six axes were identified and their contents defined. All of the axes can be viewed and searched independently, as well as in relation to each other. The axes encompass factors and service areas that impact on children, including health, education, justice, the environment and others. This has created a system that is consistent and impartial, but adaptable to an enormous variety of uses.

RESULTS

The taxonomy has been tested and validated by a number of well-respected academics, researchers and practitioners across Europe. It forms the basis of an intuitive and accessible database. This allows research knowledge to be easily identified and for networking to take place.

CONCLUSIONS

The RICHE taxonomy facilitates retrieval of knowledge - ongoing research as well as findings - in order to inform researchers and policy makers who wish to include children's health as an element of new policy.