The Effect of a Provider-Based Educational Program on Knowledge, Attitudes, Self-Efficacy, and Order Rates of Cologuard® in a Primary Care Clinic

BACKGROUND: Colorectal cancer is one of the most common and deadly cancers, particularly in persons greater than 50 years of age. Most colorectal malignancies are slow-growing, making regular screening increasingly important to decrease morbidity, mortality, and cost of treatment. Cologuard® serves as an effective and non-invasive colorectal cancer screening modality for average-risk adults. PURPOSE: The purpose of this study was to evaluate the impact of a provider-based educational intervention on the knowledge, attitudes, self-efficacy, and ordering rates of Cologuard® among primary care providers. METHODS: This study was a single-center, pre/post implementation study of the effectiveness of a provider-based educational intervention using a validated resource tool from the American Cancer Society. The first stage of the project featured a pre/post-test examination of the knowledge, attitudes, and self-efficacy related to Cologuard® of 14 primary care providers before and after an educational intervention for providers in November 2018. The second stage of the project included a separate pre/post-test design to determine the effect of the educational intervention on provider order rates of Cologuard® using 200 randomly selected charts prior to the intervention during the months of August through October 2018, and 200 randomly selected charts after the intervention during the months of December 2018 through February 2019 for patients meeting screening qualifications. RESULTS: Of the 18 providers who attended the educational program, 14 completed and returned pre- and post- tests. There was a statistically significant increase in provider knowledge (p\u3c0.001) and self-efficacy (p=0.002) from the pre- to post- intervention periods. There was no statistically significant difference in attitudes (p=0.142) or Cologuard® order rates (p=0.660) from the pre- to post- intervention periods. CONCLUSION: Provider-based educational programs serve as an effective intervention to address certain measures in practice. Increases in provider knowledge and self-efficacy related to Cologuard® were seen in the post-intervention period, and while there was not a statistically significant difference in provider attitudes, it is important to note an increase on the measurement scale did occur. Future implications for practice may involve alternate solutions to improving Cologuard® order rates, though this initiative may provide necessary first-steps to facilitate organizational changes that would lead to an increase in Cologuard® orders

The Biochemical Characterization of the Phosphatidylserine Synthase from \u3ci\u3eCandida albicans\u3c/i\u3e as a Drug Target

Treatments for Candida albicans systemic infections are limited to three classes of antifungals, some of which have harmful side effects or increasing instances of antifungal resistance. These shortcomings illustrate a need for new antifungals. The phosphatidylserine (PS) synthase, Cho1p, represents a potential drug target that can address this need. Cho1p is involved in a major phospholipid biosynthesis pathway and represents a novel drug target for three key reasons: 1) It is required for virulence, indicating that inhibitors of Cho1p would render the organism incapable of causing infection; 2) it is absent in mammals, so inhibitors potentially have no toxic side effects; and 3) the enzyme appears to be well conserved across fungi, indicating that inhibitors could be broadly effective against many fungal pathogens. In order to take full advantage of Cho1p as a drug target, we performed several screens of small molecules for ones that inhibit Cho1p. In one screen we identified SB-224289 that seems to act by inducing large scale endocytosis. A second screen identified the compound Lee-3664 which demonstrates selective toxicity against C. albicans. Further, we performed a detailed biochemical characterization of Cho1p where we identified substrate binding sites as well as the Km and apparent Vmax for each substrate. Computational modeling has produced a useful model of what Cho1p might look like and has further increased interest in crystallizing the protein in future work. The results of this dissertation will lead to more direct approaches for finding Cho1p inhibitors, leading ultimately to more effective antifungals, as well as a greater understanding of enzymes involved in phospholipid biosynthesis, which is necessary for virulence in this pathogen

An attempt to isolate the precursors of off flavor in oxidized dehydrated sweet potato flakes

Recent studies of the development of "off flavor" in dehydrated sweet potato flakes have implicated a lipid fraction containing a small amount of carotenoid epoxide. The fraction also appeared to contain other compounds which could be the precursors of such "off flavor." The major objective of this research was to isolate the compounds present in this lipid fraction and to determine the relationship of these compounds to "off flavor" in oxidized dehydrated sweet potato flakes

Relating gastric scintigraphy and symptoms to motility capsule transit and pressure findings in suspected gastroparesis

BackgroundWireless motility capsule (WMC) findings are incompletely defined in suspected gastroparesis. We aimed to characterize regional WMC transit and contractility in relation to scintigraphy, etiology, and symptoms in patients undergoing gastric emptying testing.MethodsA total of 209 patients with gastroparesis symptoms at NIDDK Gastroparesis Consortium centers underwent gastric scintigraphy and WMCs on separate days to measure regional transit and contractility. Validated questionnaires quantified symptoms.Key ResultsSolid scintigraphy and liquid scintigraphy were delayed in 68.8% and 34.8% of patients; WMC gastric emptying times (GET) were delayed in 40.3% and showed 52.8% agreement with scintigraphy; 15.5% and 33.5% had delayed small bowel (SBTT) and colon transit (CTT) times. Transit was delayed in ⠥2 regions in 23.3%. Rapid transit was rarely observed. Diabetics had slower GET but more rapid SBTT versus idiopathics (P ⠤ .02). GET delays related to greater scintigraphic retention, slower SBTT, and fewer gastric contractions (P ⠤ .04). Overall gastroparesis symptoms and nausea/vomiting, early satiety/fullness, bloating/distention, and upper abdominal pain subscores showed no relation to WMC transit. Upper and lower abdominal pain scores (P ⠤ .03) were greater with increased colon contractions. Constipation correlated with slower CTT and higher colon contractions (P = .03). Diarrhea scores were higher with delayed SBTT and CTT (P ⠤ .04).Conclusions & InferencesWireless motility capsules define gastric emptying delays similar but not identical to scintigraphy that are more severe in diabetics and relate to reduced gastric contractility. Extragastric transit delays occur in >40% with suspected gastroparesis. Gastroparesis symptoms show little association with WMC profiles, although lower symptoms relate to small bowel or colon abnormalities.Wireless motility capsule (WMC) findings in suspected gastroparesis and relations to symptoms have been poorly defined. Evaluation of patients with gastroparesis symptoms revealed gastric emptying delays with WMCs that were similar to scintigraphy, were related to reduced contractility, and were often associated with extragastric or generalized transit delays; symptoms correlated poorly with WMC profiles. These findings provide insight into motor abnormalities in gastroparesis pathogenesis and form a basis for future investigations studying the impact of WMC testing on clinical care.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141493/1/nmo13196.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/141493/2/nmo13196_am.pd

SB-224289 Antagonizes the Antifungal Mechanism of the Marine Depsipeptide Papuamide A

In order to expand the repertoire of antifungal compounds a novel, high-throughput phenotypic drug screen targeting fungal phosphatidylserine (PS) synthase (Cho1p) was developed based on antagonism of the toxin papuamide A (Pap-A). Pap-A is a cyclic depsipeptide that binds to PS in the membrane of wild-type Candida albicans, and permeabilizes its plasma membrane, ultimately causing cell death. Organisms with a homozygous deletion of the CHO1 gene (cho1ΔΔ) do not produce PS and are able to survive in the presence of Pap-A. Using this phenotype (i.e. resistance to Pap-A) as an indicator of Cho1p inhibition, we screened over 5,600 small molecules for Pap-A resistance and identified SB-224289 as a positive hit. SB-224289, previously reported as a selective human 5-HT1B receptor antagonist, also confers resistance to the similar toxin theopapuamide (TPap-A), but not to other cytotoxic depsipeptides tested. Structurally similar molecules and truncated variants of SB-224289 do not confer resistance to Pap-A, suggesting that the toxin-blocking ability of SB-224289 is very specific. Further biochemical characterization revealed that SB-224289 does not inhibit Cho1p, indicating that Pap-A resistance is conferred by another undetermined mechanism. Although the mode of resistance is unclear, interaction between SB-224289 and Pap-A or TPap-A suggests this screening assay could be adapted for discovering other compounds which could antagonize the effects of other environmentally- or medically-relevant depsipeptide toxins

Overproduction of Phospholipids by the Kennedy Pathway Leads to Hypervirulence in Candida albicans

Candida albicans is an opportunistic human fungal pathogen that causes life-threatening systemic infections, as well as oral mucosal infections. Phospholipids are crucial for pathogenesis in C. albicans, as disruption of phosphatidylserine (PS) and phosphatidylethanolamine (PE) biosynthesis within the cytidine diphosphate diacylglycerol (CDP-DAG) pathway causes avirulence in a mouse model of systemic infection. The synthesis of PE by this pathway plays a crucial role in virulence, but it was unknown if downstream conversion of PE to phosphatidylcholine (PC) is required for pathogenicity. Therefore, the enzymes responsible for methylating PE to PC, Pem1 and Pem2, were disrupted. The resulting pem1Δ/Δ pem2Δ/Δ mutant was not less virulent in mice, but rather hypervirulent. Since the pem1Δ/Δ pem2Δ/Δ mutant accumulated PE, this led to the hypothesis that increased PE synthesis increases virulence. To test this, the alternative Kennedy pathway for PE/PC synthesis was exploited. This pathway makes PE and PC from exogenous ethanolamine and choline, respectively, using three enzymatic steps. In contrast to Saccharomyces cerevisiae, C. albicans was found to use one enzyme, Ept1, for the final enzymatic step (ethanolamine/cholinephosphotransferase) that generates both PE and PC. EPT1 was overexpressed, which resulted in increases in both PE and PC synthesis. Moreover, the EPT1 overexpression strain is hypervirulent in mice and causes them to succumb to system infection more rapidly than wild-type. In contrast, disruption of EPT1 causes loss of PE and PC synthesis by the Kennedy pathway, and decreased kidney fungal burden during the mouse systemic infection model, indicating a mild loss of virulence. In addition, the ept1Δ/Δ mutant exhibits decreased cytotoxicity against oral epithelial cells in vitro, whereas the EPT1 overexpression strain exhibits increased cytotoxicity. Taken altogether, our data indicate that mutations that result in increased PE synthesis cause greater virulence and mutations that decrease PE synthesis attenuate virulence

Motility of the antroduodenum in healthy and gastroparetics characterized by wireless motility capsule

The wireless motility capsule (WMC) measures intraluminal pH and pressure, and records transit time and contractile activity throughout the gastrointestinal tract. Our hypothesis is that WMC can differentiate antroduodenal pressure profiles between healthy people and patients with upper gut motility dysfunctions.This study aims to analyze differences in the phasic pressure profiles of the stomach and small intestine in healthy and gastroparetic subjects.Data from 71 healthy and 42 gastroparetic subjects were analyzed. The number of contractions (Ct), area under the pressure curve and motility index (MI = Ln (Ct *sum amplitudes +1)) were analyzed for 60 min before gastric emptying of the capsule (GET), (gastric window) and after GET (small bowel window) and results between groups were compared with the Wilcoxon rank sum test.Significant differences were observed between healthy and gastroparetic subjects for Ct and MI ( P  < 0.05). Median values of the motility parameters in gastric window were Ct = 72, MI = 11.83 for healthy and Ct = 47, MI = 11.12 for gastroparetics. In the small bowel, median values were Ct = 144.5, MI = 12.78 for healthy and Ct = 93, MI = 12.12 for gastroparetics. Diabetic subjects with gastroparesis showed significantly lower Ct and MI compared with healthy subjects in both gastric and small bowel windows while idiopathic gastroparetic subjects did not show significant differences.The WMC is able to differentiate between healthy and gastroparetic subjects based on gastric and small bowel motility profiles.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78624/1/j.1365-2982.2010.01468.x.pd

Clinical‐histological associations in gastroparesis: results from the Gastroparesis Clinical Research Consortium

Background  Cellular changes associated with diabetic (DG) and idiopathic gastroparesis (IG) have recently been described from patients enrolled in the Gastroparesis Clinical Research Consortium. The association of these cellular changes with gastroparesis symptoms and gastric emptying is unknown. The aim of this study was to relate cellular changes to symptoms and gastric emptying in patients with gastroparesis. Methods  Earlier, using full thickness gastric body biopsies from 20 DG, 20 IG, and 20 matched controls, we found decreased interstitial cells of Cajal (ICC) and enteric nerves and an increase in immune cells in both DG and IG. Here, demographic, symptoms [gastroparesis cardinal symptom index score (GCSI)], and gastric emptying were related to cellular alterations using Pearson’s correlation coefficients. Key Results  Interstitial cells of Cajal counts inversely correlated with 4 h gastric retention in DG but not in IG (r = −0.6, P  = 0.008, DG, r = 0.2, P  = 0.4, IG). There was also a significant correlation between loss of ICC and enteric nerves in DG but not in IG (r = 0.5, P  = 0.03 for DG, r = 0.3, P  = 0.16, IG). Idiopathic gastroparesis with a myenteric immune infiltrate scored higher on the average GCSI (3.6 ± 0.7 vs 2.7 ± 0.9, P  = 0.05) and nausea score (3.8 ± 0.9 vs 2.6 ± 1.0, P  = 0.02) as compared to those without an infiltrate. Conclusions & Inferences  In DG, loss of ICC is associated with delayed gastric emptying. Interstitial cells of Cajal or enteric nerve loss did not correlate with symptom severity. Overall clinical severity and nausea in IG is associated with a myenteric immune infiltrate. Thus, full thickness gastric biopsies can help define specific cellular abnormalities in gastroparesis, some of which are associated with physiological and clinical characteristics of gastroparesis.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/92097/1/j.1365-2982.2012.01894.x.pd

Wireless pH-motility capsule for colonic transit: prospective comparison with radiopaque markers in chronic constipation

Colon transit (CT) measurements are used in the management of significant constipation. The radiopaque marker (ROM) method provides limited information.We proposed to validate wireless motility capsule (WMC), that measures pH, pressure and temperature, to ROM measurement of CT in patients with symptomatic constipation evaluated at multiple centers. Of 208 patients recruited, 158 eligible patients underwent simultaneous measurement of colonic transit time (CTT) using ROM (Metcalf method, cut off for delay >67 h), and WMC (cutoff for delay >59 h). The study was designed to demonstrate substantial equivalence, defined as diagnostic agreement >65% for patients who had normal or delayed ROM transit.Fifty-nine of 157 patients had delayed ROM CT. Transit results by the two methods differed: ROM median 55.0 h [IQR 31.0–85.0] and WMC (43.5 h [21.7–70.3], P  < 0.001. The positive percent agreement between WMC and ROM for delayed transit was ∼80%; positive agreement in 47 by WMC/59 by ROM or 0.796 (95% CI = 0.67–0.98); agreement vs null hypothesis (65%) P  = 0.01. The negative percent agreement (normal transit) was ∼91%: 89 by WMC/98 by ROM or 0.908 (95% CI = 0.83–0.96); agreement vs null hypothesis (65%), P  = 0.00001. Overall device agreement was 87%. There were significant correlations ( P  < 0.001) between ROM and WMC transit (CTT [ r  = 0.707] and between ROM and combined small and large bowel transit [ r  = 0.704]). There were no significant adverse events.The 87% overall agreement (positive and negative) validates WMC relative to ROM in differentiating slow vs normal CT in a multicenter clinical study of constipation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79053/1/j.1365-2982.2010.01517.x.pd

Overproduction of Phospholipids by the Kennedy Pathway Leads to Hypervirulence in Candida albicans

Candida albicans is an opportunistic human fungal pathogen that causes life-threatening systemic infections, as well as oral mucosal infections. Phospholipids are crucial for pathogenesis in C. albicans, as disruption of phosphatidylserine (PS) and phosphatidylethanolamine (PE) biosynthesis within the cytidine diphosphate diacylglycerol (CDP-DAG) pathway causes avirulence in a mouse model of systemic infection. The synthesis of PE by this pathway plays a crucial role in virulence, but it was unknown if downstream conversion of PE to phosphatidylcholine (PC) is required for pathogenicity. Therefore, the enzymes responsible for methylating PE to PC, Pem1 and Pem2, were disrupted. The resulting pem1Δ/Δ pem2Δ/Δ mutant was not less virulent in mice, but rather hypervirulent. Since the pem1Δ/Δ pem2Δ/Δ mutant accumulated PE, this led to the hypothesis that increased PE synthesis increases virulence. To test this, the alternative Kennedy pathway for PE/PC synthesis was exploited. This pathway makes PE and PC from exogenous ethanolamine and choline, respectively, using three enzymatic steps. In contrast to Saccharomyces cerevisiae, C. albicans was found to use one enzyme, Ept1, for the final enzymatic step (ethanolamine/cholinephosphotransferase) that generates both PE and PC. EPT1 was overexpressed, which resulted in increases in both PE and PC synthesis. Moreover, the EPT1 overexpression strain is hypervirulent in mice and causes them to succumb to system infection more rapidly than wild-type. In contrast, disruption of EPT1 causes loss of PE and PC synthesis by the Kennedy pathway, and decreased kidney fungal burden during the mouse systemic infection model, indicating a mild loss of virulence. In addition, the ept1Δ/Δ mutant exhibits decreased cytotoxicity against oral epithelial cells in vitro, whereas the EPT1 overexpression strain exhibits increased cytotoxicity. Taken altogether, our data indicate that mutations that result in increased PE synthesis cause greater virulence and mutations that decrease PE synthesis attenuate virulence