Using mHealth App to Support TKR Decision Making for Knee Arthritis Patients

Introduction: Mobile health (mHealth) technology can be used to integrate into medical decision making for patients with advanced knee arthritis. We explored patient preferences on content and design of a mobile health app to facilitate daily symptom capture and summary feedback reporting, in order to inform treatment decisions, including use of total knee replacement surgery (TKR). Methods: We developed an Android-based smart phone app for knee arthritis patients to assess arthritis symptoms and individual readiness for TKR surgery. Patient focus groups were conducted to gather requirements for mHealth app development and to refine the design and content of the app. Clinician (physical therapist, surgeon) interviews were conducted to understand clinician expectations from the summary trend report generated by the app. Results: Sixteen patients attended focus groups with an average age of 67 and 63% female, and three clinicians participated in clinician interviews. The preliminary findings revealed that the patients preferred easy tap user interfaces to multi-tap or slider methods, and vertical question layout to horizontal orientation. Patients liked to be engaged by progress feedback reports and educational tips. Both patients and clinicians found a trended outcome summary report helpful which provides more precise details on whether and how the symptoms are changing over time. Discussion: User input can inform the design and implementation of mHealth technology to deliver tailored knowledge to patients through a user-defined, patient-centered smart phone app. The tool will support future knee arthritis patient decisions regarding the need for, and timing of TKR surgery

Polymerase chain reactions using Saccharomyces, Drosophila and human DNA predict a large family of protein serine/threonine phosphatases

AbstractUsing the polymerase chain reaction (PCR) to examine the protein serine/threonine phosphatase (PP) family which includes PP1, PP2A and PP2B, we have identified two, seven, and four novel protein phosphate genes in Saccharomyces cerevisiae, Drosophila melanogaster and Homo sapiens, respectively. Consequently, the genes in the PP1/PP2A/PP2B family now number 11, 15 and 12 in these species respectively, and the data predicts still more unidentified phosphatases in higher eukaryotes. The PCR analyses also point to the presence in Drosophila and mammals of three or more different genes encoding PP2B, the enzyme recently identified as the target of certain immunosuppressant drugs

mHealth technologies for osteoarthritis self-management and treatment: A systematic review

Osteoarthritis is a common chronic disease that can be better treated with the help of self-management interventions. Mobile health (mHealth) technologies are becoming a popular means to deliver such interventions. We reviewed the current state of research and development of mHealth technologies for osteoarthritis self-management to determine gaps future research could address. We conducted a systematic review of English articles and a survey of apps available in the marketplace as of 2016. Among 117 unique articles identified, 25 articles that met our inclusion criteria were reviewed in-depth. The app search identified 23 relevant apps for osteoarthritis self-management. Through the synthesis of three research themes (osteoarthritis assessment tools, osteoarthritis measurement tools, and osteoarthritis motion monitoring tools) that emerged from the current knowledge base, we provide a design framework to guide the development of more comprehensive osteoarthritis mHealth apps that facilitate self-management, decision support, and shared decision-making

Plexin-B1 Activates NF-κB and IL-8 to Promote a Pro-Angiogenic Response in Endothelial Cells

The semaphorins and their receptors, the plexins, are proteins related to c-Met and the scatter factors that have been implicated in an expanding signal transduction network involving co-receptors, RhoA and Ras activation and deactivation, and phosphorylation events. Our previous work has demonstrated that Semaphorin 4D (Sema4D) acts through its receptor, Plexin-B1, on endothelial cells to promote angiogenesis in a RhoA and Akt-dependent manner. Since NF-\u3baB has been linked to promotion of angiogenesis and can be activated by Akt in some contexts, we wanted to examine NF-\u3baB in Sema4D treated cells to determine if there was biological significance for the pro-angiogenic phenotype observed in endothelium. METHODS/PRINCIPAL FINDINGS: Using RNA interference techniques, gel shifts and NF-\u3baB reporter assays, we demonstrated NF-\u3baB translocation to the nucleus in Sema4D treated endothelial cells occurring downstream of Plexin-B1. This response was necessary for endothelial cell migration and capillary tube formation and protected endothelial cells against apoptosis as well, but had no effect on cell proliferation. We dissected Plexin-B1 signaling with chimeric receptor constructs and discovered that the ability to activate NF-\u3baB was dependent upon Plexin-B1 acting through Rho and Akt, but did not involve its role as a Ras inhibitor. Indeed, inhibition of Rho by C3 toxin and Akt by LY294002 blocked Sema4D-mediated endothelial cell migration and tubulogenesis. We also observed that Sema4D treatment of endothelial cells induced production of the NF-\u3baB downstream target IL-8, a response necessary for angiogenesis. Finally, we could show through co-immunofluorescence for p65 and CD31 that Sema4D produced by tumor xenografts in nude mice activated NF-\u3baB in vessels of the tumor stroma. CONCLUSION/SIGNIFICANCE: These findings provide evidence that Sema4D/Plexin-B1-mediated NF-\u3baB activation and IL-8 production is critical in the generation a pro-angiogenic phenotype in endothelial cells and suggests a new therapeutic target for the anti-angiogenic treatment of some cancer

Direct-to-Patient PRO Collection to Support Quality Improvement in TJR

Introduction: Patient-reported outcomes (PROs) are widely used in orthopedic clinical research to evaluate quality of care. However, it is difficult to capture complete post-operative PRO data through surgeon office visits. The UK and Sweden collect post-TJR PRO measures directly from patients in their homes. We compared two US post-operative PRO collection processes- PROs in clinic at scheduled office visits and direct-to-patient collection, to evaluate timing and completeness of both approaches. Methods: At a large TJR center that has collected PROs at office visits routinely for years, post-TJR patients complete a PRO survey on a computer at follow-up clinic visits. In contrast, the national FORCE-TJR cohort manages post-operative PRO surveys across dozens of offices by sending PROs to patients directly via web-based questionnaires or scannable paper forms. We calculated post-operative PRO response rates and timing from these two approaches and compared patient physical outcomes between them. Results: In the clinic, 892 patients had TJR surgery during the study period. Of these, 392 (44%) completed post-operative surveys; 115 (29%) between 5 months and 7 months after surgery, and 85 (22%) after 7 months. Direct to patient PRO surveys were centrally distributed in month 5 after surgery. Of 11,702 TJR patients, 8283 (71%) completed the PRO survey within 5 to 9 months post-op. Of these, 90% were returned between 5 and 7 months. SF36 PCS scores were comparable between these two approaches. Discussion: While PRO collection at the office visit can support individual patient care decisions, patients return to the surgeon office at varied time points after TJR based on their recovery progress and convenience. Direct to patient PRO collection with appropriate retention processes can lead to uniform data timing and optimal completeness. Quality monitoring programs will benefit from consistent data across providers and should consider these factors in designing PRO procedures

Translating clinical and patient-reported data to tailored shared decision reports with predictive analytics for knee and hip arthritis

INTRODUCTION: New informatics tools can transform evidence-based information to individualized predictive reports to serve shared decisions in clinic. We developed a web-based system to collect patient-reported outcomes (PROs) and medical risk factors and to compare responses to national registry data. The system generates predicted outcomes for individual patients and a report for use in clinic to support decisions. We present the report development, presentation, and early experience implementing this PRO-based, shared decision report for knee and hip arthritis patients seeking orthopedic evaluation. METHODS: Iterative patient and clinician interviews defined report content and visual display. The web-system supports: (a) collection of PROs and risk data at home or in office, (b) automated statistical processing of responses compared to national data, (c) individualized estimates of likely pain relief and functional gain if surgery is elected, and (d) graphical reports to support shared decisions. The system was implemented at 12 sites with 26 surgeons in an ongoing cluster randomized trial. RESULTS: Clinicians and patients recommended that pain and function as well as clinical risk factors (e.g., BMI, smoking) be presented to frame the discussion. Color and graphics support patient understanding. To date, 7891 patients completed the assessment before the visit and 56% consented to study participation. Reports were generated for 98% of patients and 68% of patients recalled reviewing the report with their surgeon. CONCLUSIONS: Informatics solutions can generate timely, tailored office reports including PROs and predictive analytics. Patients successfully complete the pre-visit PRO assessments and clinicians and patients value the report to support shared surgical decisions

Translating Comparative TJR Outcomes for Performance Improvement to Guide Surgical Quality Improvement

Background/Purpose: With the CMS decision to publicly report hospital-specific post-operative total joint replacement (TJR) complications and readmissions, orthopedic surgeons need new sources of post-operative outcome data to monitor and improve post-hospital care. The AHRQ funded research program, Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), developed methods to capture longitudinal patient-reported outcomes (PROs) and comprehensive post-TJR medical and surgical events, and established a web reporting system to return comparative outcome reports to participating surgeons and hospitals in order to monitor and improve quality and outcomes. Methods: This national cohort/registry captures post-TJR measures directly from patients in their homes to assure uniform time, completion, and consistency for data comparisons across hospitals. Quarterly updated web reports deliver hospital- and surgeon-specific TJR outcomes compared with those of their peers and risk-adjusted national benchmarks on PROs as well as on post-operative event rates. Results: Our national cohort enrolled 25,000 patients from 150 diverse orthopedists in 22 US states with varied hospital and surgeon practices. The secure, HIPAA compliant website was established that presents summary and risk-adjusted comparative statistics for primary TJR for all enrolled patients. The website provides a downloadable and printable report and an Executive Summary of key pre-operative patient risk factors, post-operative events, and post-operative PROs enabling the providers to compare their outcomes to the other participating sites. Individual patient reports are available for surgeons with real-time scores and trended outcome data to facilitate patient and surgeon shared treatment decision making. Conclusion/Implications: A secure reporting website was established to disseminate comparative outcome reports to all participating hospitals and surgeons. Returning comparative outcome data to hospitals and surgeons encourages their active participation in this national registry and allows them to undstand their relative performance compared to peers while supporting practice-level quality monitoring and improvement efforts in patient care

Integrating Patient-reported Symptoms in the Arthritis Care Record

Background For knee and hip arthritis patients, self-assessed pain and physical function are central to treatment decisions as well as to clinical and outcomes research. Both paper and electronic health records capture the clinician’s summary of the patient symptoms. Brief patient-reported arthritis symptom assessments have been broadly tested and validated in clinical research, yet have not been integrated into routine office practice. The introduction of electronic health records offers an opportunity for patient direct-entry and real-time scores of standardized symptom assessments to be included in the routine health record. Purpose To both support patient-centered health care in arthritis care and to track aggregate outcomes for longitudinal research, a comprehensive arthritis care record system was designed and implemented with the goal of integrating standardized symptom assessments and clinical metrics in an individual patient health record. Trend pain and function metrics over time, Provide real-time data to patients and clinicians to inform treatment decisions, and, Track aggregate outcomes for quality assessment and research. Study Design The data collection and management system was implemented in the Arthritis and Total Joint Center (TJC) ambulatory clinic at UMass Medical Center. The host system allows development and delivery of custom web-based surveys and serves as a database archive system with interfaces to hospital information services (HIS) and a data storage location. The survey data are divided into 21 tables representing clinical categories (e.g., pain, function, clinical diagnoses) with 259 measures, and 66 among them are used for QA reports. The patient-entered survey data are merged with the clinical data in a structured format, providing comprehensive longitudinal records for individual patients. In addition, real-time symptom trend reports are produced using query, search and analysis functions. System Use The core system was established in 2007, fully operational in 2008, and by June 2010, over 1,000,000 clinical measures had been collected from over 30,000 patients visiting the Arthritis and Total Joint Center (TJC). Among patient measures, around 400,000 measures (28,500 surveys) are related to patient self-assessed symptoms. Conclusions The system implemented in our clinic is a successful model for collecting and integrating patient symptom data with clinical data as part of a patient health record. This template is the foundation for a newly funded national research registry for comparative effectiveness in total joint replacement surgery (FORCE-TJR)

Sharing Patient Disease Data with Privacy Preservation

When patient data are shared for studying a specific disease, a privacy disclosure occurs as long as an individual is known to be in the shared data. Individuals in such specific disease data are thus subject to higher disclosure risk than those in datasets with different diseases. This problem has been overlooked in privacy research and practice. In this study, we analyze disclosure risks for this problem and identify appropriate risk measures. An efficient algorithm is developed for anonymizing the data. An experimental study is conducted to demonstrate the effectiveness of the proposed approach

Variables As Currency: Linking Meta-Analysis Research and Data Paths in Sciences

Meta-analyses are studies that bring together data or results from multiple independent studies to produce new and over-arching findings. Current data curation systems only partially support meta-analytic research. Some important meta-analytic tasks, such as the selection of relevant studies for review and the integration of research datasets or findings, are not well supported in current data curation systems. To design tools and services that more fully support meta-analyses, we need a better understanding of meta-analytic research. This includes an understanding of both the practices of researchers who perform the analyses and the characteristics of the individual studies that are brought together. In this study, we make an initial contribution to filling this gap by developing a conceptual framework linking meta-analyses with data paths represented in published articles selected for the analysis. The framework focuses on key variables that represent primary/secondary datasets or derived socio-ecological data, contexts of use, and the data transformations that are applied. We introduce the notion of using variables and their relevant information (e.g., metadata and variable relationships) as a type of currency to facilitate synthesis of findings across individual studies and leverage larger bodies of relevant source data produced in small science research. Handling variables in this manner provides an equalizing factor between data from otherwise disparate data-producing communities. We conclude with implications for exploring data integration and synthesis issues as well as system development