Population health management of low-density lipoprotein cholesterol via a remote, algorithmic, navigator-executed program.

BACKGROUND: Implementation of guideline-directed cholesterol management remains low despite definitive evidence establishing such measures reduce cardiovascular (CV) events, especially in high atherosclerotic CV disease (ASCVD) risk patients. Modern electronic resources now exist that may help improve health care delivery. While electronic medical records (EMR) allow for population health screening, the potential for coupling EMR screening to remotely delivered algorithmic population-based management has been less studied as a way of overcoming barriers to optimal cholesterol management. METHODS: In an academically affiliated healthcare system, using EMR screening, we sought to identify 1,000 high ASCVD risk patients not meeting guideline-directed low-density lipoprotein-cholesterol (LDL-C) goals within specific system-affiliated primary care practices. Contacted patients received cholesterol education and were offered a remote, guideline-directed, algorithmic cholesterol management program executed by trained but non-licensed "navigators" under professional supervision. Navigators used telephone, proprietary software and internet resources to facilitate algorithm-driven, guideline-based medication initiation/titration, and laboratory testing until patients achieved LDL-C goals or exited the program. As a clinical effectiveness program for cholesterol guideline implementation, comparison was made to those contacted patients who declined program-based medication management, and received education only, along with their usual care. RESULTS: 1021 patients falling into guideline-defined high ASCVD risk groups warranting statin therapy (ASCVD, type 2 diabetes, LDL ≥ 190 mg/dL, calculated 10-year ASCVD risk ≥7.5%) and not achieving guideline-defined target LDL-C levels and/or therapy were identified and contacted. Among the 698 such patients who opted for program medication management, significant LDL-C reductions occurred in the total cohort (mean -65.4 mg/dL, 45% decrease), and each high ASCVD risk subgroup: ASCVD (-57.2 mg/dL, -48.0%); diabetes mellitus (-53.1 mg/dL, -40.0%); severe hypercholesterolemia (-76.3 mg/dL, -45.7%); elevated ASCVD 10-year risk (-62.8 mg/dL, -41.1%) (P<0.001 for all), without any significant complications. Among 20% of participants with reported statin intolerance, average LDL-C decreased from baseline 143 mg/dL to 85 mg/dL using mainly statins and ezetimibe, with limited PCSK9 inhibitor use. In comparison, eligible high ASCVD risk patients who were contacted but opted for education only, a 17% LDL-C decrease occurred over a similar timeframe, with 80% remaining with an LDL-C over 100 mg/dL. CONCLUSIONS: A remote, algorithm-driven, navigator-executed cholesterol management program successfully identified high ASCVD risk undertreated patients using EMR screening and was associated with significantly improved guideline-directed LDL-C control, supporting this approach as a novel strategy for improving health care access and delivery.

Extending i2b2 into a framework for semantic abstraction of EHR to facilitate rapid development and portability of Health IT applications.

The wide gap between a care provider's conceptualization of electronic health record (EHR) and the structures for electronic health record (EHR) data storage and transmission, presents a multitude of obstacles for development of innovative Health IT applications. While developers model the EHR view of the clinicians at one end, they work with a different data view to construct health IT applications. Although there has been considerable progress to bridge this gap by evolution of developer friendly standards and tools for terminology mapping and data warehousing, there is a need for a simplified framework to facilitate development of interoperable applications. To this end, we propose a framework for creating a layer of semantic abstraction on the EHR and describe preliminary work on the implementation of this framework for management of hyperlipidemia and hypertension. Our goal is to facilitate the rapid development and portability of Health IT applications.

Photochemical degradation of oil products in seawater monitored by 3D excitation emission matrix (EEM) fluorescence spectroscopy: implications for coloured dissolved organic matter (CDOM) studies.

Fluorescence 3D excitation emission matrix (EEM) spectra of oil products in artificial seawater were monitored as a function of irradiation time in a solar simulator. EEMs were obtained for an excitation range of 240-400 nm and an emission range of 248-830 nm; this is the wavelength range typically used in chromophoric dissolved organic matter (CDOM) EEM studies in natural waters. This allows for comparison to prior work on CDOM in an oil-contaminated salt marsh that attributed a fluorescent component in the tryptophan/tyrosine protein-region to oil. For comparison, EEMs were also measured for a broader excitation range of 220-400 nm typically used in oil related studies to capture the primary oil peak at lower excitation wavelengths. Fluorescence intensities in both excitation wavelength ranges decayed exponentially with irradiation time consistent with first-order kinetics. There was little change in wavelength for primary oil peaks. However, in the CDOM, wavelength range peaks typically shifted to longer excitation and shorter emission wavelengths, moving into the protein peak region of the CDOM EEM spectrum. This is consistent with a decrease in the complexity of the structure of the organic material. Half-lives for photodegradation ranged from 0.36 to 7.2 days for the oil wavelength range and 0.14 to 28 days for the CDOM wavelength range. Higher density oils typically had higher degradation rate constants. Peak locations and peak behaviour are consistent with the primary fluorophore in the oil products being PAH-related.

The cell cycle regulatory factor TAF1 stimulates ribosomal DNA transcription by binding to the activator UBF.

Control of ribosome biogenesis is a potential mechanism for the regulation of cell size during growth, and a key step in regulating ribosome production is ribosomal RNA synthesis by RNA polymerase I (Pol I). In humans, Pol I transcription requires the upstream binding factor UBF and the selectivity factor SL1 to assemble coordinately on the promoter. UBF is an HMG box-containing factor that binds to the rDNA promoter and activates Pol I transcription through its acidic carboxy-terminal tail. Using UBF (284-670) as bait in a yeast two-hybrid screen, we have identified an interaction between UBF and TAF1, a factor involved in the transcription of cell cycle and growth regulatory genes. Coimmunoprecipitation and protein-protein interaction assays confirmed that TAF1 binds to UBF. Confocal microscopy showed that TAF1 colocalizes with UBF in Hela cells, and cell fractionation experiments provided further evidence that a portion of TAF1 is localized in the nucleolus, the organelle devoted to ribosomal DNA transcription. Cotransfection and in vitro transcription assays showed that TAF1 stimulates Pol I transcription in a dosage-dependent manner. Thus, TAF1 may be involved in the coordinate expression of Pol I- and Pol II-transcribed genes required for protein biosynthesis and cell cycle progression.